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THP] CEREBRO-SPINAL FLUID;
ITS SPONTANEOUS ESCAPE FROM
THE NOSE.
WITH OBSERVATIONS ON ITS COMPOSITION
AND FUNCTION IN THE HUMAN SUBJECT.
BY
StCLAIR THOMSON, M.D., M.R.C.P.Lond.,
■' F.RC.S.Eng.
PHYSICIAN TO THE THROAT HOSPITAL, OOLDEN SQUARE ; SUEOKON TO
THB ROYAl. EAR HOSPITAL, LONDON
NEW YORK:
WILLIAM WOOD AND COMPANY.
MDCCCXCIX.
/S99
c/
WTfONAl LfBRARY OF MEDJCii^
- 6£TH£SDA 14, MB, -^-^
PREFACE.
Two and a half years ago I discovered that a young
woman in apparently good health, and without any tangible
cause, was suffering from the escape of cerebro-spinal
fluid from one side of the nose. This produced no other
symptom than the mechanical one of inconvenience. The
flow was at first intermittent in its appearance, but for
more than three years it has been continuous both day and
night, — with only four intermissions, one of these lasting
for sixteen days, two lasting for twenty-eight days, and
the other for two months. To all intents and purposes the
patient remains in perfect health ; indeed, as regards
attacks of headache to which she had been subject, she is
even better than she was before this flow commenced.
An attempt to establish a hitherto unrecognised patholo-
gical possibility on the observation of a single case might
be met with the objection which occurs in French law.
Testis unus, testis nullus. But a prolonged and extensive
search through medical literature has convinced me that,
while the condition is probably one of exti'eme rarity, still
similar cases have already been published, although in the
majority of instances the exact source of the fluid which
escaped from the nose was overlooked, and the discharge
was ascribed to hypersecretion from the mucous mem-
brane. I have, however, succeeded in collecting the
records of twenty other cases, and their study is made the
more interesting by the fact that most of them were asso-
iv
PEEPACE.
ciated with cerebral symptoms and some with retinal
changes.
In this way the recognition of a single case of cerebro-
spinal rhinorrhoea has led to the collection and considera-
tion of others occurring in literature, and has enabled me
to give a description of a condition which will help to the
discovery of other cases, and to a more complete study of
the subject.
The patient in whom this curious phenomenon occurred
attended the clinic of my colleague Dr. J. W, Bond, to
whom I have to expi-ess my great indebtedness for kindly
permitting me to make full observations on the case.
Apart from the clinical aspect of the condition, the unique
opportunity was afforded for making a series of observa-
tions on the composition and function of the cerebro-
spinal fluid in the human subject.
These have already been published in vol. Ixiv of the
'Proceedings of the Royal Society' in a conjoint paper
by Professor Halliburton, Dr. Leonard Hill, and myself,
and the conclusions arrived at have been incorporated in
the following pages. I have to thank Professor Halli-
burton most cordially for freely placing at my disposal not
only his very special knowledge of the physiological
chemistry of cerebro-spinal fluid, but also his valuable
time in repeatedly making most thorough analyses of the
various samples of fluid I have submitted to him.
StCLAIR THOMSON.
28, Queen Anne Steeet, W. ;
April, 1899.
CONTENTS.
Part I. — The Spontaneous Escape op Cerebro-spinal
Fluid from the Nose.
PAGE
Historical . . . . . .3
Escape of Cevebro-spinal Fluid from the Cranium . . 5
A. From the Ear, after Injury . - .5
B. From the Ear, Spontaneously . . .6
Case published by Escat . . . .6
c. From the Nose, after Injury . . .7
Case published by Mathiesen . . -9
„ Vieusse . . .9
Spontaneous Escape from the Nose not a Recognised Sym-
ptom . . . . . .10
Author's Case . . • • .13
Complete Analysis of Cerebro-spinal Fluid . . 17
The Sterility of the Nasal Fossae . . .20
Progress of the Author's Case . . .21
Intermissions in the Flow . . .21
Patient's present Condition . . .22
Other Published Cases :
Group A. — Cases in which the Discharge from the
Nose was undoubtedly Cerebro-spinal Fluid . 24
Case I.— Published by Tillaux . . .24
Case II.— Published by Leber . . .26
Case III.— Published by J. Toison and E. Lenoble 28
Case IV.— Published by F. Wallace Mackenzie . 31
Case V. — Published by Gutsche . . .33
Case VI.— Published by Mermod . . 34
Case VII.— Published by StClair Thomson . 37
Case VIII.— Published by Scheppegrell . . 38
Case IX.— Published by Korner . . 40
Table of Nine undoubted Cases . . .44
vi
CONTENTS,
PAGE
Group B. — Cases in which the Discharge from the
Nose was most probably Oerebro-spinal Fluid . 49
Case X.— Published by King . . .49
Case XI.— Published by Elliotson . . 50
Case XII.— Published by Paget . . . 51
Case XIII.— Published by H. Fischer . . 54
Case XIV.— Published by W. R. Speirs , . 55
Case XV.— Published by B. B. Baxter . . 66
Case XVI.— Published by Nettleship . . 57
Case XVII.— Published by Priestley Smith . 59
Case XVIII.— Published by Priestley Smith . 60
Case XIX. — Published by Emrys-Jones . . 62
Case XX.— Published by Berg . . .63
Case XXI.— Published by Lichtwitz . . 64
Other possible cases published by Willis . . 67
Morgagni . . 68
„ „ Nothnagel . . 68
Groh . . 69
E. Meyer . . 69
Berg . . 70
Flatau . . 71
„ „ Prosser James . 71
Table of Twelve Probable Cases . . . .76
Summary of Twelve Probable Cases . . .80
Diagnosis from Nasal Hydrorrhoea . . .81
Poulsson's Case of Marked Nasal Hydroi'rhcea . . 81
Analysis of Secretion in Nasal Hydrorrhoea . . 83
Chemical Composition of Cerebro- spinal Fluid . . 86
Diagnosis from so-called Dropsy of the Antrum . . 88
Anderson's Case of Nasal Hydrorrhoja . . 88
Serous Accumulation in the Maxillary Sinus . . 89
Diagnosis from Water inspired and retained . . 94
Diagnosis from Vaso-motor Neuritis . , .95
Diagnosis from Ruptured Lymph Tubes . . .95
Mules' Case of Lymph Nsevus of the Eye . . 96
Difference between Lymph and Cerebro-spinal Fluid . 98
Summary of Evidence in support of Gi'oup " B " . .99
Clinical Picture of Cerebro-spinal Rhinorrhcea . . 103
Chemical Tests for Cerebro-spinal Fluid . , 104
Pathology ...... 109
Hydrocephalus Internus .... Ill
The Cerebral Symptoms in the majoi-ity of cases , 114
CONTENTS.
VU
PAGE
Pathology :
Route of Exit from the Cranial Cavity . . 116
Route of Exit through the Lymph Channels . . 117
Treatment . . . . . .120
Conclusion. ...... 121
Part II. — Observations on the Composition akd Function
OF THE CerKBRO-SPINAIi FlUID IN THE HUMAN SUBJECT.
Physical and Chemical Properties of Cerebro-spinal Fluid . 125
Sterility of Fluid and Rate of Flow . . . 126
Comparison of the Morning and Evening Fluid . . 125
Intra-vascular Injection of the Cerebro-spinal Fluid . 127
The Influence of Straining and Posture on the Flow and
Composition of the Fluid .... 128
Experiments made with Abdominal Compression . . 131
PAKT I.
THE CEEEBEO-SPINAL ELUID ;
ITS SPONTANEOUS ESCAPE FROM THE NOSE
IN TWENTY-ONE INSTANCES.
THE CEREBRO-SPINAL FLUID ;
ITS SPONTANEOUS ESCAPE FROM THE NOSE.
Historical.
A EEPEEENCE to Landois and Stirling's * Text-book of
Human Physiology/ published in 1885, shows how little
was known at that date of the cerebro-spinal fluid, the
only notice of it being a quotation from Hoppe-Seyler.
Indeed it is remarkable that, until the recent work of
Halliburton,-^ little has been added to our knowledge of
this liquid since 1842, when Magendie published his
* Recherches sur le Liquide Cephalo-Rachidien,' in order,
as he writes, to place beyond doubt the normal existence
of this fluid. Previous to that date knowledge of the
secretion in question had been very confused and un-
satisfactory. Galen repeatedly speaks of an excrementi-
tial liquid, expressed from several points of the brain
into the ventricles, especially into the fourth, where it is
stored, and then purged into the nose through the
ethmoid bones and infundibulum. It is here curious to
note that although Galen was of course mistaken in think-
ing that this was a physiological procedure, yet I hope to
show the possibility of such a route as he imagined. It
is difiicult to say if Galen's opinions were the result of
direct observation, or if they were merely speculative.
After his period, Massa, Yesalius, Vidus-Yidius, and
Varoli refer to a watery humour in the brain. In the
^ ' Chemical Physiology and Pathology,' London, 1891, p. 355.
4
THE CEEEBRO-SPINAL FLUID.
sixteenth century we find Sansovino ^ still calliug the
nasal cavity the " cloaca del cerebro." Schneidei* ^
finally showed how baseless was the fabric of the ana-
tomical vision which saw any free communication between
the nose and the ventricles of the brain.
It was not till the time of our own Willis ^ that the
method of direct observation was brought to bear on the
question as to what became of the cerebro-spinal fluid, a
question which appears to have considerably puzzled the
elder anatomists. Willis acknowledges that it is at first
sight difficult to see how this fluid passes off through the
holes in the cribriform plate, since they are completely
blocked during life by the nerve fibres and the prolonga-
tions of the dura mater. Yet he holds that it is permis-
sible to think that the fluid descends into the nose by
openings which are invisible after death, but dilatable
during life " by heat and the spirit." But Vieussens *
points out that the pituitary membrane cannot be the ex-
cretoiy surface for the aqueous humour of the bi^ain. He
had opened many crania and found a quantity of water in
individuals who had never during life voided anything
similar by the nose or mouth. The following experiments
confirm this view : — He poured alcohol into the anterior
fossa of the skull and left it there some time ; not a drop
escaped from the nose, not even when the dura mater was
stripped off the ethmoid. Besides, if a living animal is
taken, and the two carotids and jugulars ligatured, and
coloured alcohol is then injected into the carotids until all
the vessels are distended, he found that the cavities of the
brain will be flooded, but that nothing will escape from
the nose.
Cotugno (1736-1822)," who gave his name to the
1 F. Sansovino, ' L' edificio del corpo umano,' Venet., 1550 (ref . in Zucker-
kandl).
' ' Liber de esse cribriformi/ &c., and ' De catharris,' Wittenbergse, 1655.
'Opera Omnia,' Geneva, 1695, "Anatom. Cerebri," chaps, xi, xii, andxiii.
* ' De natura et necessitate spiritus animalis et de succo nervoso.'
* ' De Ischiade Nervosa,' Neapoli, 1764, in Sandifort's ' Thesaurus Disserta-
tionum,' Koterodami, 1769.
ESCAPE FEOM THE EAR, AFTER INJURY.
5
Liquor Cotunniij calculates the amount in the cadaver
at about four to five ounces ; but although he had found
the fluid in living fish and turtles^ he is sceptical as to
its existence in the living human subject.
It is interesting to note that the work of Willis,
Yieussens, and Cotugno, must have been strangely
overlooked for it to be necessary for Magendie to, so to
speak, rediscover this fluid. The fact is another con-
firmation of the saying that nothing is new except what
has been forgotten.
Escape op Cerebro- spinal Fluid prom the Cranium.
A. From the Ear, after Injury.
That the cerebro-spinal fluid can escape from the
cranium in cases of injury has been known for some
time. As early as the year 1727 Stalpartius van der
Wiel (' Observat rarior. cent, prior.,' Obs. xv),^ pub-
lished a case in which large quantities of a thin, clear,
watery fluid had escaped from the ear for several days
after a severe injury to the head. O'Halloran and Dease
published cases, but these appear to have been lost sight of
until Laugier called attention to the co-existence of a
watery discharge and rupture of the membrana tympani
in some cases of fracture of the base.^ The character of
the fluid was not recognised at first, but it was established
by Nelaton, Eobert, Rabourdin, Chatin, and Deschamps.^
Guthrie * held that the fluid probably came from the
cavity of the arachnoid, and pointed out that it was
symptomatic of great danger. This accident is now, of
course, a matter of common observation.
1 Quoted in Holmes' ' System of Surgery,' Srd edit., vol. i, 1883, p. 592.
2 ' Comp. Rend, de I'Acad. des Sci.,' 1839, p. 240.
3 'Bulletin de I'Acad. de Med.,' xviii, 7 dec, 1852, p. 240.
* " On Injuries of the Head affecting the Brain," * Med.-Chir. Eeview,'
No. 76, 1841, p. 302.
6
THE CEEEBRO-SPINAL FLUID.
B. From the Ear, spontaneously.
The possibility of cerebro-spinal fluid escaping sponta-
neously from the ear had not entered my mind when I
first commenced to interest myself in this subject, and it
was only during the preparation of this paper that I met
with the record of a case published by Escat (of Toulouse) }
His patient was a girl aged 10, who eighteen months previously
had first noticed the escape of a clear watery fluid from the right
ear. The flow was intermitting, it lasted a few minutes, then
stopped abruptly, but recurred ten or twelve times in the day.
This state of things lasted two months, and then ceased suddenly
under no special treatment. A year later the same phenomenon
reappeared, and lasted about a month. Finally the flow again
appeared eight days before the patient was brought for advice on
the 8th May, 1897. There was no previous history of consequence,
no ear trouble, no introduction of foreign body, and no history of
accident. The flow came on without apparent cause. A few
seconds before it appeared there was a whistling in the right ear,
which ceased as soon as the liquid began to flow. At each escape
about half a tumbler of liquid was lost, and the total quantity in
twenty-four hours was calculated at half a litre. The flow con-
tinued during the night, and in the daytime the patient was
obliged to wear over the right ear a large linen compress, which
required frequent renewal. The flow was generally more abundant
during the three hours after meals, and the patient noticed that
she could increase it by straining. During one flowing 150 grammes
were easily collected, and submitted to Professor Gerard, who re-
ported as follows :
" The liquid is undoubtedly cerebro-spinal fluid, as the following
analysis shows :
Colourless liquid, limpid, faintly alkaline, very slight turbidity
with heat in presence of acetic acid.
" Chloride of sodium . . . 6*3 gr. per litre.
Earthy phosphates (or PHjOj) . 0"4 „ „
Traces of cholesterin and albumin."
In spite of this flow the patient's general health was satisfac-
tory. She complained of no pain or malaise, and although her
parents noticed some lassitude and intellectual torpor during the
flow, this was not marked, and she continued her work and play at
school as formerly.
^ ' Archiv. Internat. de Laryngologie,' tome x, No. 6, 1897.
ESCAPE EEOM THE NOSE, AFTER INJURY.
7
Direct examination of the right ear showed that the tympanic
membrane, including Shrapnell's membrane, was quite intact, and
the Eustachian catheter indicated that the middle ear was free of
liquid. The external two thirds of the auditory meatus showed
nothing abnormal ; but in the inner third, on the upper wall, a fine
white line was detected. This did not disappear after cleansing ;
and although suction with Siegle's speculum failed to draw any
liquid from it, and a fine probe could not detect any corresponding
crack or depression, yet Escat decided that this spot indicated the
point of escape of the fluid from the cranial cavity. He applied the
galvano-cautery to it, and the flow ceased and had not recurred two
months later.
In his conclusions from tbis case the author exchided
traumatism or any ulcei-ative process. He regarded it
as due to a congenital defect, or at least predisposed to
by a congenital atrophy of the upper wall of the external
auditory meatus, which became more marked in the course
of the development of the temporal bone and ended in a
genuine partial absorption of the floor of the temporal fossa.
When compared with the cases I have been able to
collect there can be little doubt that this was indeed
an instance of spontaneous escape of cerebro-spinal fluid
from the external auditory meatus. Although the
analysis does not give the specific gravity, nor mentions
the substance which reduces Fehling's solution, it is yet
sufficiently complete to exclude the question of its being
other than arachnoid fluid.
I am inclined to ask for some reserve in attributing a
cure to the sealing of the cuticular opening with the
cautery. If the bone is really defective it is likely that
the fluid will break its way through the cicatrix whenever
the pressure becomes increased. For we must note that
the flow had on two previous occasions ceased spontane-
ously, once for a whole year.
c. From the Nose, after Injury.
The escape of the fluid from the nose as a consequence
of injury does not appear to have been so frequently
observed. The first suggestion of such a condition is
8
THE CEEEBRO- SPINAL FLOID.
given by Bidloo the elder/ a medical writer who lived in
the second half of the seventeenth century and wrote a
work on surgery. In this he reports the case of a
patient who had an accident to the bridge of the nose,
followed by a continuous flow of a clear watery secretion
from the right nostril in such quantity that within
twenty -four hours 20 ounces (600 c.c.) of this fluid
escaped. Later on the discharge became purulent,
splinters of bone came awa}'^, and the patient died seven
months after the receipt of the accident.
Blandin ^ in 1840 opined that he himself was the first to
note an enormous serous flow from the nose in certain cases
after injury. He pointed out the great importance of this
new symptom for diagnosis, and especially for prognosis.
A confirmatory observation is given in full by Robert.^
That recovery in such cases may be complete and satis-
factory is shown by a case of Hector Cameron's.* A
man aged 75 was thrown down stairs and suffered from
"profuse bleeding from his left ear and nostril, followed
by the discharge of large quantities of clear fluid. The
discharge of cerebro-spinal fluid continued for several
days, ceasing from the ear before it did so from the
nostril.^' The patient recovered completely.
In the following case the dischai-ge persisted for much
longer, viz. for two months, before it finally ceased. It
is important to recognise that a cerebro-spinal rhinor-
rhcea, if I may be allowed the term, could persist so long,
as patients might present themselves for the nasal dis-
charge some time after the receipt of the accident, to
which they might possibly omit any reference. This case
is recorded by Mathiesen.^
1 Quoted by Morgagni, ' De sedibus et causis morborum,' liber i, epist. xiv,
art. 21.
2 ' Gazette des Hopitaux,' 1840, p. 205.
3 'Archives generales de Medecine/ 1845, tome ix, p. 389.
4 • Brit. Med. Journ.,' May I7th, 1884, p. 886.
* 'Norsk. Magazin for Laegevidenskaben,' p. 241, January, 1887 (from
abstract in Bosworth's 'Diseases of the Nose and Throat,' vol. i, 1889,
p. 266).
ESCAPE FROM THE NOSE, AFTER INJURY.
9
Traumatic Cerehro- spinal Uhinorrhoea lasting Ttvo Months.
The patient was a boy aged 13, wlio bad a severe fall on tbe left
temple, following wbich be Avas unconscious for some time. Tbe
following nigbt be suffered from vomiting and epistaxis. About
two montbs after tbe accident be came under observation on
account of tbe discbarge of a tbin watery secretion of a salty taste
from tbe left nasal cavity. In tbe course of two bours 25 centi-
metres of tbis fluid were collected. His general bealtb was good.
Five days later tbe discbarge ceased. Microscopical examination of
tbe fluid revealed wbite blood-corpuscles, a few fcbreads of mucus, and
pavement epitbelium. Tbe fluid was of a specific gravity of 1"006,
and of alkaline reaction, contained albumen, salt, and sugar, and
otberwise corresponded to a cerebro-spinal fluid. Tbe writer was in
doubt if tbe source of tbe discbarge was tbe cerebral or tbe nasal
cavity.
It is well known tliat fractures of the base of the skull
sometimes escape attention, and from this point of view it
is advisable to bear in mind that when the anterior fossa
of the skull is involved, a cerebro-spinal rhinorrhoea may
not only be an important symptom, but even, as in the
following case, the only one. The patient in this instance,
after receipt of a fracture through the cribriform plate
and the left middle fossa, was able to drive hi& bullock
cart, partly on foot, a distance of twenty-five miles ; in-
deed he did not seek advice until eight days after the
accident, and then he only came on account of a clear
watery discharge from the nose.
The case is thus reported by Yieusse : ^
A man aged 46, immediately after a fall from a bullock-cart, was
stunned, and altbougb there was a blood-stained discbarge from
tbe left ear and from the nose, be was able to continue his journey
of 40 kilometres, part of it on foot. Eight days afterwards he pre-
sented himself with a dropping of very limpid fluid from tbe nose
at tbe rate of about two drops per second (? per minute). On
lying down tbis flow quite ceased, and was replaced by a similar
1 • Gazette Hebd. de Medecine et de Chirurgie,' tome xvi, 1879, No. 19,
p. 298.
10
THE CEREBRO-SPINAL FLUID.
discharge from the left ear. By placing the patient in a sitting
position and then in a horizontal one, these discharges could be
made to alternate regularly. The liquid was not collected; the
author was so convinced of its nature that an analysis appeared
useless. Eighteen days after the accident the patient died with
symptoms of meningo-encephalitis. This was confirmed at the
autopsy, which revealed a fracture of the base in the anterior fossa,
involving the cribriform plate, and the middle fossa on the left side
through the temporal bone.
Spontaneous Escape from the Nose not a Recognised
Symptom.
But although this escape of cerebro-spinal fluid from
the nose in traumatic cases is a recognised occurrence, and
reference to it is to be found in most surgical text-books, I
was chiefly interested in seeing whether a case under my
own observation was unique in its spontaneous character,
or whether there were already records to supply the points
which are wanting to make a complete picture of this patho-
logical condition. So far as many well-known text-books
are concerned this search has been fruitless. Such classical
systems of medicine as Ziemssen's (' Cyclopeedia of the Prac-
tice of Medicine/ 1881) and Russell Reynolds' {' A System
of Medicine,' 1872) have no mention of such a possibility,
and there is no reference to it in the text-books of
Bristowe {' Theory and Practice of Medicine,' 1890), Osier,
or of Hilton Fagge and Pye-Smith {' Principles and Prac-
tice of Medicine,' 1891). Although, as I will show later
on, this symptom appears to be frequently associated with
nervous symptoms, there is no hint of it in Gowers' well-
known Avork {' Diseases of the Nervous System,' 1893) nor
in the large * Text-book of Nervous Diseases by American
Authors ' (edited by Francis X. Dercum, Edinburgh and
London, 1895). It is remarked by von Jaksch ('Clinical
Di agnosis,' third English edition, 1897, p. 108) that "oc-
casionally, as in cases of wounds perforating the cranium
and in brain tumours, cerebro-spinal fluid may be dis-
SPONTANEOUS ESCAPE FEOM THE NOSE.
11
charged througli the nose. Under sucli circumstances,
chemical analysis showing the absence of albumen and the
presence of sugar, or at least of a reducing substance,
will determine the diagnosis." Here, as elsewhere, it is
evident the idea is not even entertained that cerebro-
spinal fluid can be discharged from the nose except as a
result of injury or brain tumour. Turning now to publi-
cations dealing specially with diseases of the nose, I find
that the subject is in no way referred to by Morell
Mackenzie {' Diseases of the Throat and Nose,^ 1884,
vol. ii) or Lennox Browne {' The Throat and Nose,' 5th
edition, 1899). In the German edition of Mackenzie's
work {' Die Krankheiten des Halses und der Nase,' Morell
Mackenzie and Felix Semon, Berlin 1884) reference is
made to the cases of Morgagui (p. 68), Bidloo (p. 8),
and Elliotson (p. 50), and also to those of Paget (p. 51),
Nettleship (p. 57), and Priestley Smith (p. 59), without
suggesting the possibility that the watery flow was caused
by escape of cerebro-spinal fluid. Bosworth gives in-
stances of several cases which were obviously escape of
cerebro-spinal fluid through the nose (f Diseases of the
Nose and Throat,' vol. i, 1889), but he does not appear to
have realised the origin of the fluid, and he groups these
cases under the heading of ''Nasal Hydrorrhoea " with
cases of nervous coryza, suppuration in the antrum, and
various other diseases of the nose. He ascribes the con-
dition to a vaso-motor paresis of the nasal mucosa occur-
ring in subjects of an intensely neurotic temperament.
The excellent text-book of Moritz Schmidt {' Die Krank-
heiten der oberen Luftwege,' Zweite Auflage, 1897) has
no reference to the question at issue. Rosenthal {' Die
Erkrankungeu der Nase,' Berlin, 1897) does not mention
it, but under the title of " Rhinitis Chronica Simplex " he
includes some cases which later on I will claim to be
possible examples of the condition I am considering. The
very encyclopeedic work by various German authors, which
is now issuing from the press in three large volumes
{' Handbuch der Laryngologie und Rhinologie,' edited by
12
THE CEREBEO-SPINAL FLUID.
Paul Heymann_, Wien, 1896-7-8), gives no reference to
the occurrence of spontaneous flow of cerebro-spinal fluid
from the nose, but simply a mention of hydrorrhcea
nasalis as a watery flow wlaicli may be symptomatic of
injury of the skull, of hydrocephalus, or of affections of
the accessory sinuses. Spencer Watson (' Diseases of the
Nose,' 2nd edition, 1890, p. 38) gives a careful considera-
tion to the question of watery dischai'ge from the nose, but
he comes to the conclusion that " there is a possibility of
the fluid being cerebro-spinal and that it escapes through
a fissure in the cribriform plate of the ethmoid. That
such an origin is the true one can only be after a severe
injury and as a consequence of a fracture of the base of
the skull.''
Summary.
This last quotation summarises the generally accepted
view as to the question of the escape of cerebro-spinal fluid
from the nose, viz. that while it may occur as consequence
of injury, and is a rare accompaniment of brain tumour, its
spontaneous escape is unknown. So far from being a recog-
nised possibility, it remains unnoticed in many of the best
known and most recent publications on general medicine,
nervous diseases, and affections of the nose. The ' Journal
of Laryngology ' in twelve years does not mention it. The
thirteen volumes of the ' Centralblatt fiir Laryngologie '
contain in the index only three references under the title
of " Cerebro-spinal Fliissigkeit." It is evident that the
condition is most exceptional, or else that its true nature
is very rarely recognised. However, by the help of these
and other references I have succeeded in tracing eight
other cases where an analogous condition was undoubted,
and twelve cases where it was most probable.
None of these cases have had the advantage of being
so thoroughly investigated as one I am able to record, either
because the opportunity did not offer, or because physio-
logical chemistry was not till recently sufiiciently advanced
to speak authoritatively on the composition of the fluid. I
author's case.
13
think it will be better, therefore, to report this case in its
entirety, and then refer to those which help to make up the
parts in the clinical picture of the affection.
Author's Case.
My patient, R. W — , is a single woman aged 25. She
has been born and brought up in the country, where she
has attended to the domestic duties of her mother's cottage.
She first attended the Throat Hospital, Golden Square, in
April, 1896. She was seen to be a healthy-looking young
woman, presenting no exophthalmos, nor any striking
feature suggestive of disease. Two and a half years pre-
viously she had gradually become aware of an increasing
tendency to drip fi-om the left nostril. This would occa-
sionally stop for a week or even a month at a time, but since
Christmas, 1895, it had been continuous both day and night.
The nature and source of the fluid were overlooked at first,
and she was treated with iron tonics, and locally with
alkaline nose lotions. There was no cessation of the flow,
and on May 20th, 1896, some post-nasal growths were
scraped away under nitrous oxide gas. The dripping con-
tinued as before, and it remained unaltered by nasal lotions
of extract of hamamelis, and a long course of Fowler's
solution.
In October, 1896, the intractability of the flow caused
me to give the case a fuller examination, and my intei'est
was keenly aroused on finding that when the patient
inclined her head forwards a clear watery fluid fell from
her left nostril in a steady drip, much as the blood does
in epistaxis. The following observations were then
made. This dripping — which had at that date been
unabated for ten months — runs forwards as a rule, and
it escapes more rapidly when she bends her head. When
she inclines her head backwards, or when she lies on her
back, the liquid runs down into her throat, and she then
has to swallow it. At night it sometimes runs on to her
14
THE CEREBRO-SPINAL FLUID.
lip, and so on to the pillow ; this especially occurs if she
is lying on the left {i. e. the affected) side. When she is
in bed ib also runs into her mouth and causes her to
swallow, but she says that it never gives rise to choking
attacks. However, her mother states that when sleeping
in the same room with her she was frequently alarmed by
the gurgling and choking noises made by the patient in
her sleep.
She had noticed that the flow was invariably from the
left side ; it appeared to her to be worse when she had a
cold ; it had never been blood-stained nor offensive ; was
free from disagreeable taste and odour; its escape gave
rise to no sneezing or irritation, and her sense of smell
had remained quite unaffected.
She prefers to let the liquid flow forward, and in
order to arrest it from dropping on to her clothes or the
work she may be engaged on, she is compelled to carry a
handkerchief in her left hand from morning to night.
When working at a table she simply places a handkerchief
directly under her nose, and allows the fluid to drip on to
it. She uses five to six handkerchiefs a day, and these
handkerchiefs on being dried are found to be quite pliable,
and do not dry stiff as they would in cases of mere increase
of mucous secretion. This point has some importance in
reference to the consideration I purpose giving later on to
previously recorded cases in which this fact was observed,
although the indication it afforded was not appreciated.
Coming now to the examination of the nose, it is seen
that there is very slight excoriation of the left upper lip
and vestibular orifice. With the exception of slight con-
gestion along the margin of the left middle turbinal, the
inside of the nasal fossa is quite normal. The septum is
slightly deviated, and there is a small spur on each side,
though nothing but what is quite physiological. The post-
nasal space is quite clear ; the veins on the posterior
wall of the pharynx are larger than usual. In the right
nasal fossa no discharge of any kind is to be detected.
If the left side is examined in the ordinary manner — i.e.
author's case.
15
by tilting the head somewhat backwards^ — no fluid can
be detected^ for in that position it runs into the naso-
pharynx^ and, as is evidenced by the movement of deglu-
tition, it is then swallowed. But if the patient stands up
with the head bent forwards, and the physician remains
seated in front of her — as in Killian's position for viewing
the posterior laryngeal wall — he will be able to see with
a nasal speculum that the fluid collects between the septum
and the middle turbinal, and that when this space (the
olfactory cleft) is filled the liquid runs forwards between
the agger nasi and the septum until it gains the upper part
of the vestibule, whence it drops from the tip of the nose.
There are no carious teeth in the upper jaw; no differ-
ence between the two sides of the face is noticeable on
transilluminating the head from the mouth ; and there is
no suspicion of any of the accessory cavities of the nose
being affected.
The patient's general health is good, and she has
always been considered healthy. She eats and sleeps
well, does not suffer unduly from thirst, the bowels act
regularly, the urine is healthy, mez)struation takes place
naturally, and the heart and lungs are normal. The
thyroid gland is not enlarged. There is no affection of
motion or sensation ; the reflexes are normal ; she is not
subject to giddiness or vomiting. The hearing is normal.
The fundus of each eye was examined, but there was no
trace of retinitis or optic atrophy. This observation was
kindly confirmed by Mr. Adams Frost and Mr. Vernon
Cargill. The former reported her eyes to be in every
way normal. Her intelligence is good and her memory
is clear ; she is somewhat shy and nervous, and it would
appear that she dislikes being in public as she fancies
that people notice her complaint and the constant use she
is compelled to make of her pocket handkerchief.
As to her previous history, she has never had influenza
that she knows of. She states that four years ago she
was in bed for fourteen days with headache and vomiting ;
but her family attendant. Dr. Eadie of Yeovil, informs
16
THE CEREBEO-SPINAL FLUID.
me that this illness was o£ a bilious character, and that he
remembers nothing about her case out of the ordinary
character, except that her convalescence was rather pro-
tracted. She had measles and congestion of the lungs
three years ago, and suffered, so she says, from a good
deal of headache afterwards. Dr. Badie was told that
she fainted or had " fits,^' but he never saw her in any
of these attacks. He writes that the headaches under
treatment got better, and he formed the opinion that she
was rather hysterical. I have inquired carefully into
the history for indications of attacks of convulsions, de-
lirium, or unconsciousness, but there appears never to
have been anything of the sort. She has never met with
any accident to her head, nor had any operative treat-
ment to her nose.
In her family there is no trace of any similar affection.
Her father was found dead on the roadside ; he was a
rather heavy drinker, and had twice had rheumatic fever.
Her mother is alive and well, and as I have fully inquired
into the rest of her family history, I need only say that
it presents no bearing on her condition.
The patient informed me that she had been subject to
headaches ever since childhood ; these were always better
when the fluid was escaping from the nose, and since the
flow has become continuous the headaches have been most
remarkable by their absence ; indeed, now they occur only
rarely and are very slight. The headaches used to last
sometimes for weeks ; they were most intense over the
left eyebrow, outer side of left orbit, and the centre of
the occipital region.
This history when considered with the one-sidedness of
the flow, the absence of other possible sources, and the
macroscopic appearance of the secretion, suggested to me
the possibility that I had to do with a case of escape of
cerebro-spinal fluid from the nose.
I therefore directed the patient to " drip " for ten
minutes into a sterilised glass capsule. It was observed
that in the first minute the number of drops was seven,
COMPLETE ANALYSIS.
17
in tlie second minute six, and in tlie third minute five.
After this the dripping continued without decreasing
frequency, at the rate of five drops per minute. This
average would amount to five drachms in an hour, and
fifteen ounces in twentj^-four hours. The fluid was sent
to Dr. Hewlett, the pathologist of the Throat Hospital,
who kindly sent me the following report :
"British Institute op Preventive Medicinb;
" Blst October, 1896.
" The specimen of nasal fluid forwarded by Dr. StClair Thomson
has the following reactions :
" 1. "With acetic acid it gives no precipitate, indicating absence of
mucus.
" 2. Boiled with Fehling's solution it gives a distinct reduction.
" 3. Proteids are practically absent.
" In these reactions it resembles cerebro-spinal fluid rather than
nasal mncus.
" Cultivations made from the fluid and incubated at 22° C. and
37° C, four in number, were all negative."
Four days later the same quantity of fluid was collected
in a sterilised capsule, and again examined by Dr. Hewlett
with exactly the same results. There was no longer any
doubt that the case was as I suspected. I therefore
availed myself of Professor Halliburton's kindness, and
of his special knowledge as the leading authority on the
chemistry of this fluid. He confirmed Dr. Hewlett's
report.
Complete Analysis of the Fluid from the Nose.
"Report on fluid received from Dr. StOlair Thomson, 16th
November, 1896.
" The fluid was received in sterilised glass vessels in two portions.
One portion stated by the patient to have been collected in the
course of one hour measured 4 c.c. The other portion collected
under Dr. StClair Thomson's immediate supervision in ten minutes
measured 3 9 c.c. If the fluid is secreted at this rate all day, the
B
18
THE CEREBRO-SPINAL FLUID.
total quantity in twenty-four hours would be 561"6 cc, or over liali
a litre.
" The fluid is perfectly clear and colourless. It looks like water.
The reaction of the fluid is faintly but distinctly alkaline. The
specific gravity of the fluid, estimated by weighing, is 1005. It
contains a trace of proteid coagulable by heat and acetic acid ; but
the quantity is too small to give more than an opalescence.
" In another portion of the fluid it was ascertained that this proteid
is practically all precipitable by saturation with magnesium sulphate ;
is is therefore a globulin.
The fluid contains a substance which reduces Fehling's solution.
This substance is not sugar, as it does not ferment with yeast. A
portion of the fluid was treated with excess of acidified alcohol ; the
proteid was thus precipitated ; this was filtered off". The filtrate
was evaporated to dryness over a water-bath ; the dry residue was
again taken up with alcohol, filtered, and again evaporated to dry-
ness. Part was evaporated to dryness on a glass slide ; the residue,
examined microscopically, was seen to contain the needle-like
crystals, single and in bundles, similar to those previously de-
scribed and figured by me (' Journal of Physiology,' vol. x, p. 248)
as obtainable from cei'ebro-spinal fluid (Vide Plate). The residue
had also the characteristic pungent taste of pyrocatechin.
" The remainder of the dry residue was dissolved in water, filtered,
and the filtrate reduced Fehling's solution well, but did not ferment
with yeast. A control experiment showed that the yeast used was
active on a sugar solution.
" The quantity of material at my disposal did not admit of a more
thorough examination of it than is described above ; but I have no
hesitation, from what I have done, in pronouncing the fiuid to be
cerebro-spinal fluid.
" It is like cerebro-spinal fluid in appearance, reaction, and specific
gravity.
" It is like cerebro-spinal fluid in its low percentage of proteid
matter (globulin) and in its absence of albumin.
" It is like cerebro-spinal fluid in containing a i-educing substance
which is not sugar, which is soluble in water and alcohol, which
does not ferment with yeast, and which, on account of these
properties together with its taste and crystalline form, is a member
of the aromatic series, probably pyrocatechin or some derivative of
that substance.
" W. D. Halliburton.
" King's College, London ;
" 18th November, 1896."
I
fj5 m.m.
Crystals from Cerebro-spinal Fluid.
20
THK CEREBRO-SPINAL J'LDID.
"Examination of other specimens of the same fluid at a later date
confirmed the foregoing conclusions. I was able to determine that
the reducing substance does not give the phenyl hydrazine test for
sugar, and that creatinine is absent. — W. D. H.
" February 28th, 1899."
The Sterility of the Nasal Fossx.
In parenthesis, I would here venture to call attention
to the fact that cultivations from the secretion showed
that the fluid was absolutely sterile. This confirms in a
remarkable manner the results of the experiments which
I had some time previously made with Dr. Hewlett, and
which we had the honour of bringing before the Royal
Medical and Chirurgical Society on the 28th May, 1895.^
We there showed that nasal mucus is generally free from
organisms, that it exerts an inhibitory action on their de-
velopment, and that, as a rule, the interior of the healthy
nose is absolutely sterile. In the case under consideration it
might, of course, be advanced that infection of the subarach-
noid space had not taken place as the flow was under a
positive pressure, and that the outward stream of cerebro-
spinal fluid would prevent the entrance of organisms.
Magendie has, indeed, shown that in animals the cerebro-
spinal fluid is under such considerable pressure, that when
the spinal cord of a living animal is exposed and the dura
mater punctured, the fluid will spurt out, sometimes to a
considerable height.^ This, of course, rapidly diminishes
as the pent-up fluid escapes, though doubtless a certain
pressure outwards always continues. But when cerebro-
spinal fluid escapes from the external ear it is under the
same amount of pressure, and as the external auditory
meatus is unprovided with the methods of defence which
are to be found in the nasal fossse, infection of the fluid
' "Micro-organisms in the Healthy Nose," by StClair Thomson and R. T.
Hewlett, 'Med.-Chir. Trans.,' vol. Ixxviii, 1895.
3 Magendie, 'Recherches sur le Liquide Cephalo-Rachidien,' Paris, 1842,
p. 6.
INTERMISSIONS IN PLOW.
2]
and consequent meningo-enceplialifcis only too frequently
ensue — at least I understand that it used to be so in the
pre-Listerian days. Certainly I think it is almost with-
out record that the cerebro-spinal fluid can trickle from
the ear for two mouths, as the result of an accident, and
yet no infection take place ; but this is what happened
with the escape from the nose in the case of Mathiesen
(p. 9), and in my case it has been escaping from the nose
for more than five years without becoming septic. This
appears to me to be a remarkable clinical confirmation of
our results, and strengthens us in our conclusion that the
interior of the nose is automatically aseptic, and is far
from being the nest of microbes which it was considered
to be before our researches were published.
Progress of the Author's Case.
To return to the progress of the case. As soon as the
nature of the nasal discharge had been positively deter-
mined, 'no intra-nasal medication whatever was attempted
from fear of infection, and the patient was strongly ad-
vised to avoid all nasal lotions, sprays, &c. The patient
was shown to the Laryngological Society on November
11th, 1896.^ From the date of the analysis— 16th
November, 1896 — to the present date, no nasal treat-
ment has been employed, some general tonic treatment was
prescribed, and the patient in the early part of 1897
returned to her home in the country. Her health re-
mained good, and the flow was reported to be the same
as before.
Intermissions in the Flow.
Only four times has it quitted her. On the 30th
August, 1897, i. e. after it had been dripping continuously
day and night for twenty months, the flow ceased, and, as
she wrote, " it stopped for a clear month to the day.''
1 ' Proceed. Laryngol. Soc..' vol. iv, 1896.
22
THE CEKEBRO-SPINAL FLUID.
At the end of this month it gradually returned, and in
the course of a foi'tnight it was flowing as much as ever.
There does not appear to have been any cause for the
cessation^ nor any for the reappearance of the dropping.
It could not be ascribed to any particular circumstance,
nor to any treatment, for she was not having any. The
flow again ceased during the months of January and
February, 1898. The cessation took place gradually,
and the flow returned in the same manner. For the
third time it ceased during the month of April. From the
5th of May, 1898, it continued day and night until the
18th February, 1899, when it ceased for sixteen days.
The patient states that during these cessations in the
flow she was not ill ; she was able to continue her work,
and was not sick, giddy, or faint. But on inquiring
closely it is clear that she was more subject to headache
when the dripping ceased, chiefly over the left eye
and the top and back of the head. The headaches did
not recur immediately on cessation of the flow, but after
two or three days. They appear to have been less severe
than in former years, before any dripping showed itself ;
but still, just at the end of February, 1898, she wrote that
she had " most severe pains over the left eye and most
dreadful at the back of the head.'^ As soon as the drop-
ping commenced again the pains ceased. With reference
to the last cessation, the patient wrote : " When it was
stopping I had no headache, and was in good health.
Two or three days before the water returned I was in
agonies of pain.'^ The nuisance which this constant
dripping is to the patient may be judged from a letter in
which she wrote to say " no one knows the misery Fm in,
so if you could possibly send me anything you thought
would stop it I should be so glad."
Patient's Present Condition.
The patient came under observation again in October,
1898. When examined on the 6th October her general
OTHER PUBLISHED CASES.
23
condition was found to be as previously described. The
dripping was taking place entirely from the left side, and
in the same manner. Her eyesight remains unimpaired,
and there is no fresh observation to add except as regards
the left nasal cavity. Here a small polypus, presumably
an oedematous fibroma, has formed, and is seen descend-
ing between the left middle turbinal and the septum.
This has probably formed from the continuous soaking of
the spongy tissues, as suggested by Bosworth in analogous
conditions.
The escape of fluid was reported to be as bad as ever
on the 18th March, 1899.
Other Published Cases,
Before drawing the conclusions which are justified by
this exceedingly curious case, and venturing on a few
speculations, I think it would be well to first place on
record the cases already recorded in literature, which
appear to me to resemble it, although in the majority of
instances they were ascribed to some other condition than
that of the escape of cerebro-spinal fluid. The com-
parisons which will then be available may help towards
an explanation of the phenomena. I must ask indulgence
for the space which these records will take up. My excuse
is that I know of only one other attempt to bring together
the records of several cases to show that spontaneous
cerebro-spinal rhinorrhoea is a clinical possibility. This
was done by Leber ^ in 1883 ; but, with the exception of
his own case, all those he quotes are cases which I only
include in a second group under the title of " most pro-
bably cerebro-spinal fluid,'' and six of the eight un-
doubted cases to which I am able to refer have occurred
since the publication of Leber's paper. Bosworth's
collection of cases under the heading of " nasal hydror-
rhcea" contains too great a variety of pathological
1 Von Graefe's ' Archiv fiir Oplithalmologie,' xxix, 1883, p. 273.
24
THE CEREBRO-SPINAL FLUID.
conditions to be of help in elucidating the phenomena in
question.
I have placed the cases in two groups (A and B), and
have numbered them in chronological order.
Group A.— Cases in which the Discharge from the Nose was
undoubtedly Cerebro-spinal Fluid.
Case I. — Tillaux. ' Traite d'Anatomie Topographique/
Paris, 1877, p. 56.
Tillaux in recording his case remai'ks that the obser-
vation is extremely rare, if not unique : —
" An optician presented Limself to me in December, 1872, for a
discbarge from tbe nose. The latter caused bitn no pain, but having
bis bead constantly bent forward over bis work, he was extremely
inconvenienced by tbe incessant dropping of liquid. 1 thought at
first of a pituitary hypersecretion produced by a coryza, and men-
tioned this idea to the patient ; he vigorously opposed the idea,
asking me to note that he had no symptoms of a cold, that the flow
was not o£ recent date, and that it was continual, especially when
he bent bis head forward, a statement which he illustrated on the
spot. When asked if he could supply some of this fluid the patient
replied, ' A litre, if you wish it.' He calculated tbe amount of flow
at a quarter of a litre in the day ; a few days later he brought two
bottles containing 200 to 300 grammes each. The fluid was analysed
by M. Mehu, who reported that it was pure cerebi-o- spinal fluid.
" On inquiring as to the patient's previous history, 1 learned that
be had twice been operated on for nasal polypi. I had no longer
any doubt that the liquid escaped from the cranium by an opening
in the roof of the nasal fossae, on the plane of the lamina cribrosa.
Further information showed that the position of tbe head bad a
considerable influence on the flow ; on holding it forward, tbe flow
was incessant ; it diminished as he raised his head, and completely
disappeared in the horizontal position. I have followed the patient
since that period; there are variations in the flow of the liquids
which has even ceased for several months without any treatment.
Except for some headache from time to time the patient does not
experience tbe least trouble, neither physical nor mental; he enjoy,
all his faculties, and, as formerly, occupies himself with his business.
I saw the patient last on September 20th, 1873, when the flow was
as abundant as ever."
CASE BY TILLAUX.
25
In this editio7i of his book the conclusion of the case is
not given, but Lichtwitz^ states that in a later edition
(4e edition, 1884, p. 54), which I have not been able to
procure, Tillaux adds a note to say that he had learnt
that the patient had died with convulsive symptoms,
A few points are wanting in this description. We are
not informed if the flow was oue-sided ; if the interior of
the nasal fossas was healthy ; if the headache varied in
relation to the flow. It is to be presumed that both eye-
sight and smell were intact, since the patient enjoyed all
his faculties. As to the disappearance of the flow when in
the lioi'izontal position, this statement probably depended
entirely on the patient's assertion, and is to be accepted
with reserve. In m}^ own case the patient was under
the impression that the flow sometimes ceased during sleep,
but the evidence of anyone sharing the same room
is that she is continually making swallowing movements
in her sleep.
The full analysis of the fluid is not given, but Mehu
was a well-known chemist, and his researches on the
composition of cerebro-spinal fluid are so frequently
quoted (his supply of the liquid probably coming from
this case) that I think there need be no hesitation in ac-
cepting his positive report as absolutely conclusive. I
would note that the flow was continuous, although subject
to variations, and that during the ten months the patient
was under observation it sometimes ceased entirely and
quite spontaneously for months at a time. It is also par-
ticularly noteworthy that the patient died with cerebral
symptoms.
Tillaux evidently connects the escape of cerebro-spinal
fluid with the operation for the removal of polypi. I am
surprised at this, for we know clinica/lly, and from
ZuckerkandFs researches,^ that the roof of the nose is
never the point of origin of mucous polypi. If the occur-
' 'Archives Cliniques de Bordeaux,' No. 12, December, 1892.
^ ' Anatomie Normale et Patliologique des Fosses Nasnles/ Traduction
Fran9aise, 1895.
26
THE CliEEBKO-SPINAL FLUID.
rence of nasal polypi in this case was not merely coinci-
dental, it is much more likely that tliey were the result of
the constant soaking of the mucous surfaces in watery fluid,
and not the cause of its flow ; unless, indeed, it is sug-
gested that the cribriform was accidentally damaged by the
surgeon.
Case II. — Th. Lebke (Gottingen) . " A Case of Hydro-
cephalus with Post-neuritic Atrophy of the Optic
Nerves, and Persistent Dropping of Watery Fluid
from the Nose.'^ Von Graefe^s ' Archiv fur Ophthal-
mologie,' xxix, 1883, I, p. 273.
A gh'l aged 15|- first came under notice in 1877 on account of
failing vision. Hydrocephalus from birtli ; always weakly and
undersized, with large head ; vision and intelligence good in child-
hood ; vision good until fifteen years old ; during the last year great
failure of vision ; latterly frequent short attacks of giddiness, with-
out loss of consciousness ; occasionally severe headache ; two
epileptic seizures. Post-neuritic ati'ophy in both discs ; exterior of
eye normal ; pupils react promptly ; vision reduced to counting
fingers and seeing movements of hand. Stature small ; with fairly
well-marked hydrocephalus; circumference of head 61 cm.; nasal
catarrh, enlarged tonsils, coryza, indurated cervical glands, carious
teeth.
From March 12fch, 1877, to end of 1881 she remained in much the
same condition ; there was no improvement in vision ; the epileptic
attacks recurred at intervals of six to eight weeks ; also much
oftener paroxysms of giddiness and headaches. Towards the end of
1881 all these manifestations showed themselves less often, and at
Christmas, 1881, continual dropping of watery fluid from the
nostril began. Up to February 5th this flow only ceased once
during a period of two days.
The fluid was watery, slightly dull (from bacterial development),
neutral, no mucin, only traces of albumen, little organic matter,
some salts, including NaCl ; except bacteria, no formed elements.
In December, 1881, as already remarked, dropping of fluid began
from the nose, and in February, 1882, she presented herself again
for examination. Vision had deteriorated, so that the right eye was
quite blind, and with the left she could count fingers. Eye move-
ments normal ; viscera normal ; urine free from sugar and albumin
intelligence intact ; no motor or sensory disturbance, except loss of
CASE BY LEBER.
27
sight and complete loss of smell. A watery fluid constantly dropped
from tb.e left nostril, especially wlien the head was bent forwards ;
when the head was held up, and during sleep, nothing was noticed,
perhaps because the flviid flowed backwards. The flow was more
plentiful in the morning than in the afternoon. Both nasal fossae
wei'e free, nothing in the throat except enlarged tonsils. The quantity
varied ; once in the morning 15 drops fell in a minute ; in an hour
22 c.c. were collected ; in six hours 76 c.c. escaped ; in seven hours and
fifty minutes 32 c c. The secretion therefore fluctuated in an hour
between 4'08, 12-6, and 22 c.c. 76 c.c. escaped in six hours.
Anahjsis of fluid. — Sp. gr. 1007-8, feebly alkaline, perfectly clear
and free from odour, slightly salty to taste ; gave no deposit on
standing ; contained a very few lymph corpuscles, which in fi-eshly-
caught drops still made distinct amoeboid movements. Certain
rounded cells showed in their interior very active molecular move-
ment. On boiling, even on addition of acetic acid, no opacity ;
with nitric acid, slight opalescence. Trommer's test gives a very
slight separation of oxide of copper. Boiling with Liquor Potassse,
a yellow colouring, which disappears on further boiling. Silver
nitrate solution gave a white precipitate ; on evaporation common
salt crystals were obtained ; on heating the slight residue on porce-
lain it became brown.
Occasionally the dropping ceased for periods varying from eight
days to four weeks. It was reported as still present when the
patient returned home. For awhile it was from the right nostril,
but afterwards from the left, as before, and her general condition
continued better than in previous years ; headache and giddiness
ceased ; convulsive seizures still occurred from time to time ; they
were not more apt to occur during the pei'iods of arrested dropping
than at other times. Vision i-emained the same.
The following analysis was supplied by Professor Tollens :
The fluid turns the ray of polarised light slightly to the left.
It reduces Fehling's solution very slightly (1 c.c. Fehling's solution
is reduced by 6"5 cc. of the fluid). This gives, reckoning for sugai',
0'077 per cent, sugar (?). Whether the reducing substance is really
to be looked upon as sugar, remains, according to this, certainly
rather doubtful. In addition were found chlorides of soda and
potash (shown by flame tests), traces of sulphates. Mixed with five
volumes of absolute alcohol, slight fine-flaked opacity. The fluid eva-
porated to dryness and the residue dissolved in water leaves a little
soft flaky substance, which is insoluble in water, alcohol, ethei", and
diluted acetic acid, and with Millon's solution gives a fine red colour
(protein material). Finally, the fluid contains traces of an acid
28
THE CBREBRO-SPINAL FLUID.
substance wliicli is uncrystalline, oily, and witli solution of per-
chloride of iron, as with chloride of lime, gives a deposit, and so
very likely is a fatty acid which is in solution in combination with
an alkali.
From tlie fulness and care with whicli Leber records
his case I gather that cerebro-spinal rhinorrhoea is not a
frequent concomitant of the hydrocephalus of children.
The analysis leaves no doubt as to the fluid being cerebro-
spinal.
In the following case the completeness of the analysis
leaves nothing to be desired ; unfortunately^ however, the
clinical history is most meagre. I have written to Paris,
but have been unable to obtain further particulars.
Case III. — J. Toison and E. Lenoble. ' Comptes Eendus
de la Societe de Biologie,' tome iii, Serie 9, 1891.
Seance du 23 Mai.
A young woman, aged 28, had four years previously had a violent
fall on a staircase. The injury affected chiefly the nape of the neck.
Afterwards the patient appeared to recover completely ; but about
four months previously (to the first date of observation, February
22nd, 1891), that is to say, towards the end of November, 1890, she
was suddenly seized with a nasal discharge which was more or less
abundant, at times very considerable, and which she regarded as
the beginning of a coryza ; but later on no other of these symptoms
appeared, and the flow persisted in varying quantity. When
examined for the first time on February 22nd, 1891, the liquid
Tsrhich escaped was found to be limpid, colourless, free from odour,
very fluid. The patient complained of its saltish taste. There was
little doubt that the case was one of escape of cerebro-spinal fluid.
Besides, a hasty examination of a few drops of the liquid showed
that it gave an abundant precipitate with nitrate of silver (chloride
of sodium), and that it gave nothing with nitric acid. The patient
collected all the liquid which escaped during six consecutive
hours ; it amounted to 75 c.c. The patient thought that on that
particular day the flow was less than usual. However, if it had
continued at the same rate during the whole day, the total amount
for the twenty-four hours would have amounted to 300 c.c.
The following very full analysis is given :
CASE BY TOISON AND LENOBLE.
29
''Microscopical examination. — Yery few white blood-cells; no red
discs, but a few short bacilli and one or two micrococci.
" Chemical analysis. — Colourless, odourless, perfectly limpid,
alkaline, and measuring 75 c.c.
" With heat a faint cloudiness which does not disappear on the
addition of a few drops of acetic acid, and which is produced even
when the liquid has been acidified beforehand.
" Acetic acid produces a development of carbonic acid.
" Nitric acid gives no precipitate.
" Acetic acid and ferrocyanide of potassium give no result.
" ISTeutral acetate of lead gives a white precipitate, soluble in
excess of the reagent.
" The liquid does not give the biuret reaction * ; but with iodide
of potassium and Millon's reagent ^ it gives a yellow precipitate
(reaction of Randolph) ; this precipitate easily becomes red under
the influence of a slight excess of the reagent.
" The density taken with the specific gravity bottle is, at + 10°,
10076. (Weight of the liquid, 62-791 gr. ; weight of the water,
62-315 gr.)
"The proportion of fixed matters was made on 5 c.c, and gave —
Organic matters .... 0 0065 gr.
Mineral matters .... 0 0440 ,,
Total solids at 100=— 110° . . . 0-0505 „
or per litre —
Organic matters .... 1*30 gr.
Mineral matt ers .... 8 80 „
Total solids ..... 10-10 „
The chlorine directly measured corresponds to 6*84 gr. of chloride
of sodium per litre.
" The greater part of the liquid was treated with an excess of
alcohol at 95° ; after twenty-four hours' rest the precipitate was
collected on a filter, washed with weaker alcohol, dried, and dissolved
in a small quantity of water.
" The solution became opalescent under the influences of heat.
It gave a precipitate with acetic acid and ferrocyanide of
potassium ; it did not reduce the cupric sulphate and caustic
potash, but it gave most distinctly the reaction of Randolph (or
what we call Millon's reaction).
" This solution, therefore, contains an albuminoid material soluble
in water after precipitation with alcohol, and giving the reaction
1 That is, violet colour with copper sulphate and caustic potash.
* A mixture of the nitrates of mercury and excess of nitric acid.
30
THE CEREBRO-SPINAL FLUID.
which is said to be characteristic of peptones (reaction of Ran-
dolph).!
" The alcoholic liquids used in the preceding steps are distilled in
order to collect the alcohol. The residue is taken up with water.
The watery solution reduces Fehling's solution ; therefore it con-
tains the reducing substance whose presence had been observed at
the beginning of the analysis.
" All the efforts made by one of us to isolate this reducing body
have been fruitless, as it occuri-ed in too small a quantity in the
liquid. Bat we have, however, been able to show that it both
reduced ammoniacal nitrate of silver, at the same time giving a
metallic mirror as aldehydes do. It also deviated the ray ot
polarised light to the rigbt. The deviation observed in a tube of a
decimetre = 1° 15'."
On another occasion [it is not mentioned at what later date] the
quantity collected during eight consecutive hours only amounted to
62 c.c, which woixld on!}' give an average of 186 grammes for the
twenty-four hours. This leads the authors to remark that this
shows that the flow had actually diminished; but the only conclu-
sion it may justify is that the flow vai'ied in quantity.
" This second sample is less transparent than the pi'eceding, less
fluid ; it contains slight clouds of mucus, but is colourless,
" Microscopical examination. — Few white blood-discs ; few short
bacilli, one or two micrococci ; no red blood-discs.
" Chemical examination. — This liquid contains a larger proportion
of organic matter, and the albuminoid matter, whicli was isolated,
iis on the former occasion, does not give clearly the reaction of
Randolph.
" The density at +10-5° is 10076 (weight of the liquid, 62-8010 gr. ;
v/eight of the water, 62'325 gr.). The fixed matters include —
Organic matters .... 0*0035 gr.
Mineral matters .... 0-0175 „
Total of solids .... 0 0210 „
Per litre the fixed matters amounted to —
Organic matters . . . .1*75 gr.
Mineral matters . . . . 8-75 „
Total of fixed mattei s . . . 10-50 „
The proportion of chlorine carried out on the ashes of 2 c.c. gave
0-033 gr. of chloride of sodium, which coi-responds to 6*72 grs. of
chloride of sodium per litre.
" Conclusions. — The results obtained may be summai-ised in the
1 This reaction is not characteristic of peptones, but a pink instead of a
violet biuret reaction is. — W. D. Hallibtteton.
CASE BY WALLACE MACKENZIE.
31
form of tlie following conclusions, wliich agree generally with those
of Mehu, except in regard to the reducing material.
" A. Cerebo-spinal fluid appears to normally contain some white
blood-globules, a fact which is easily explicable, since the white
blood- cells are found in nearly all parts of the organism.
" B. From the chemical point of view it is characterised in the
fresh condition —
" 1. By its alkaline reaction and by the absence of odour and
colour.
" 2. By a low density varying round 1007.
" 3. By the constancy of its richness (a) in mineral matters,
and amounting in our cases to between 8'30 gr. and
8'80 gr. per 1000 c.c. ; (b) in chloride of sodium (from
6-62 gr. to 6-84 gr.).
" 4. By the variability and weakness in organic and albuminoid
material. Probably, also, even the nature of these albu-
minoids is subject to variation.
" By the presence of a reducing body not pointed out by Mehu
but already suspected by Bussy, of which we have always
been able to prove the existence without being able to
determine its nature."
Unfortunately there are no clinical details with regard
to this case, other than those given in the above report.
We are therefore without information as to whether the
flow was continuous day and night, if it was one-sided or
not, if it was accompanied by any cerebral or ocular sym-
ptoms, as to the condition of the interior of the nose, and
as to the conclusion of the case.
Case IY. — F. Wallace Mackenzie. A Case of Atrophy
of the Optic Nerves, with dropping of Watery Fluid
from the Left Nostril. ' Transactions of the Inter-
colonial Medical Congress of Australasia,^ Third
Session, held in Sydney in 1892, p. 500.
A well -nourished, healthy-looking, intelligent lad at the age of
seventeen began to suffer with severe headaches and gradual failure
of sight, together with attacks in which the patient used to fall
down in a sort of fainting fit. There were apparently no convul-
sions. Well-marked optic neuritis was found in both eyes. The
sight continued to get worse, and at the end of a year a watery dis-
32
THE CEREBRO-SPINAL FLUID.
cliarge began to drop from the patient's left nostril. Coincident
witli this the fits ceased, and there had not been any return since
(i. e. after the elapse of two years).
At the age of twenty — on April 8th, 1890 — he presented himself
to the author on account of blindness and a continual dropping of a
clear watery fluid from his left nostril. There were no nasal polypi,
and no diseased condition could be detected in the nose or naso-
pharynx, nor was there any evidence of a diseased condition of the
accessory cavities. The eyes were wide open ; the pupils were partly
dilated, equal, and slightly sensitive to light. Y = p. 1. with both
eyes. There was atrophy in both optic discs, the margins being
sharply defined. There were no retinal haemorrhages. A clear
watery fluid dropped continuously from the left nostril at the rate
of about one ounce in an hour. On examination the fluid was
found to be clear and transparent; sp.gr. about 1006. On boiling
with acetic acid there was a slight cloudiness. There was a con-
siderable proportion of chlorides and a trace of sulphates present,
and the salts were principally tliose of potassium. In three different
specimens examined there was no reaction of sugar in any.
Wallace Mackenzie is of opinion that in his case the
fluid was derived from the subarachnoid space. He
adds " I look upon the early symptoms and condition as
being analogous to an attack of glaucoma, and the relief
caused by the escape of fluid through the nose may be
compared to the relief of the increased tension in the eye
by the escape of fluid through the canal of Schlemm."
The above is a most carefully recorded case, and
although deficient in some details it is the most com-
plete I have yet come across in my bibliographical
search. There is a distinct record of the condition
of the eyes and of the interior of the nasal fossae.
I have no doubt that Wallace Mackenzie was right
in regarding his case as one of nasal escape of cerebro-
spinal fluid. The history of headache and failure of
vision, of " fainting fits " which entirely ceased on the
establishment of the flow, and the one-sideduess of the
discharge, all tend to confirm this opinion. It would have
been interesting to have heard if, when the loss of vision
first came on, the left eye — the one on the side of the dis-
charge — was affected before the right. The low specific
CASE BY GUTSCHE.
33
gravity of the fluid^ and the absence of mucin, eliminate
the possibility of an intra-nasal origin of the liquid. The
analysis is particularly valuable from the negative value
it brings to bear on other cases in my bibliography.
The " reaction for sugar " was not obtained, although
three different specimens were tested. Now the negative
result of this sugar test " is adduced by Mr. Priestley
Smith for abandoning the hypothesis that the nasal fluid
was cerebro- spinal in his own two cases, as well as in
Mr. Nettleship's and Sir James Paget's. If it is agreed
that the fluid in the present ease was really of cerebro-
spinal origin, it is evident that the negative finding of the
" sugar test is not to be regarded. Besides, in examin-
ing cerebro-spinal fluid the test with Fehling's solution has
to be applied with some delicacy, so that the reaction
might be overlooked in the hands of observers who were
not used to the refinements of physiological chemistry.
Case V. — Gutsche. Dissertation, Erlangen, 1894, " Zur
Pathogenese der Hypophysistumoren und iiber den
nasalen Abfluss, sowie das Verhalten des Liquor
Cerebrospinalis bei einer Struma pituitaria."
Abstract in ' Centralblatt fiir Laryngologie,' Bd. xi,
1895, S. 460.
" The case concei-ns a man, aged 34, who, being in otherwise per-
fect health, observed that a clear fluid flowed from his left nostril,
the quantity in the course of a day amounting to about 250 c.c.
When lying down it flowed into the throat. It is remarkable that
in other cases this striking symptom of the flow from the nose of
the cerebro-spinal fluid was never mentioned. Death ensued in
about fifty-eight days after the first appearance of illness, with the
phenomena of cerebro-spinal meningitis. The post-mortem showed
struma pituitaria (swelling of the pituitary gland and of the chiasma
nervorum opticorum), empyema of the sphenoidal sinuses and of the
left maxillary antrum, and arachnitis purulenta.
" The chemical analysis of the fluid showed that it was rich in
albumin, and contained a reducing substance, which, however, could
not be desci'ibed as sugar."
0
34
THE CEREBRO-SPINAL FLUID.
To the inclusion of this case amongst those of " spon-
taneous dropping of cerebro-spinal fluid it might be
objected that there was a gross lesion at the base of
the brain, but here again the connection between the
lesions found post mortem and the cerebro-spinal flow is
not very evident. The analysis is not opposed to the
view that the fluid was cerebro-spinal ; indeed, the
presence of a reducing substance " supports it. The
large amount of albumin is explained by the admixture
with inflammatory products in the accessory sinuses.
Case VI. — Mermod. " Meningo-encephalitis consequent
on the exploration of a supposed Frontal Sinus.''
' Annal. des Mai. de I'Oreille et du Larynx/ tome
xxii, No. 4, April, 1896.
A man aged 36 had suffered for several years from painful tickling
in his nose, especially towards the root, with considerable muco-
purulent secretion, which was increased in cold, damp weather;
nasal respiration was frequently interfered with. The continuous
current, electrolysis, and application of the galvano-cautery to the
hypertrophied inferior turbinals only produced momentary relief.
When examined on July 15th, 1895, he was complaining of head-
ache, frontal or occipital, or sometimes generalised ; at times it was
a general heaviness of the head, which was very troublesome when
he was at work. He ran much from the nose, requiring two or three
handkerchiefs a day, and many more when the weather was cold or
damp ; the secretion was the same on both sides ; he had the con-
stant sensation of being stopped up in the nose. The nasal mucous
membrane was generally very red ; the inferior turbinals were not
very large, their surface rough and unequal, probably the result of
previous treatment. The middle turbinals were very irregular, and
presented that appearance of polypoid degeneration which is habitu-
ally observed in long-standing suppuration of the accessory sinuses.
The meatuses were full of muco-pus, of which it was difficult at
first to discover the source, which was probably multiple. During
the summer of 1895 the following treatment was carried out in
various sittings :— Resection of the middle turbinals, extraction of
large polypoid masses on each side from the neighbourhood of the
infundibulum ; opening of the right maxillary antrum by the
alveolar border, and of the left sphenoidal sinus, which was found
full of pus and large granulations, so that the anterior wall was
resected in order to throw the sinus and the nose into one cavity.
CASE BY MERMOD.
35
The anterior and middle ethmoidal cells on the i-ight side were
opened, and were also found to contain pns and large granulations.
Towards the end of the summer the patient experienced a certain
amount of relief, but the secretion was still vei-y abundant. When
examined on November 15th the local condition had altered. The
nose was completely free ; the aspect of the mucous membrane as a
whole was almost normal ; there was no vestige of polypus, and no
trace of pus. The lining of the left sphenoidal sinus was seen to
be rose-coloured, and the right maxillary sinus also no longer
secreted pus. But, on the other hand, the patient asserted that he
used his handkerchief more than ever, only the secretion had gradu-
ally lost its purulent character, and had become absolutely watery ;
also it was no longer continuous, but intermittent in character.
The headache had become exclusively frontal ; it was often most
severe, especially on the right side, and it diminished every time after
an abundant nasal evacuation of a liquid which was clear as water
[the italics are Dr. Mermod's] — a symptom on which the patient
particularly insisted. He was persuaded that there was "some-
thing " at the base of the forehead, and demanded relief in one way
or another, as his work as a printer was b3coming constantly more
difficult for him.
As to diagnosis. Thinking that the case might be one of vaso-
motor hydrorrhcen, the local action of cocaine, antipyrine, and atro-
piue were tried without avail. A cyst of the frontal sinus might be
suspected, and the case appeared to coincide best with the two cases
of Lichtwitz, where the nasal secretion came from the frontal sinus,
and where cure was obtained by a puncture from the nasal cavity
(vide p. 64), although, with the exception of sneezing, the nervous
symptoms — such as lachi-ymation, photophobia, temporary hemia-
nopsia, convulsive seizures, &c. (Lichtwitz) — wei'e wanting. The view
of an affection of the frontal sinus was the more probable, as otber
sinuses were involved; but why should there be pus in the maxillary
and ethmoidal sinuses on the right side and the sphenoidal on the
left, with serous fluid in the frontal sinus ? The liquid was not
thought to be cerebro-spinal, for in the curious case of Tillaux the
flow was incessant— a quarter-litre in twenty -four hours — and was not
accompanied by any sort of malaise ; besides, this quantity varied
according to the position of the head. Here there was nothing of
the sort. There was no ocular disorder ; vision equal on both sides ;
the papilla clearly limited; no venous stasis. An attempt to
catheterise the frontal sinus from the nose was not successful, the
curved cannula appearing to be arrested at the entrance of the
infundibulum, as if it terminated in a cul-de-sac. Before resorting
to Schseffer's method of puncturing the floor of the sinus from the
nose anotber attempt was made — with every antiseptic precaution
86
THE CEKEBEO-SPINAL FLUID.
— to pass a fine curved flexible probe up through the fronto-nasal
canal. It was remarked with surprise that the instrument entered
easily, without meeting with any bony resistance, into what
appeared to be a vast cavity, giving the impression of a very exten-
sive frontal sinus. On withdrawing the probe, which had penetrated
to a depth of 71 ceutimetres, from the nostril the patient's habitual
headache was much augmented for an hour, and during the night
there was an abundant serous flow from the nose. He resumed his
work next day, and returned to the clinic in eight days, when the
same manoeuvre was repeated ; but, in order to collect some of the
serous liquid, a small cannula was introduced in the same track
as on the former occasion, but only to the deptb of 6J centimetres.
Immediately some grammes of liquid, clear as water, escaped fi'om
the cannula ; the onset of sharp pain obliged the hasty withdrawal
of the cannula, and so prevented the collection of the liquid,
Meningo-enceplialitis followed, and on the sixth day a large opening
of the frontal region at the i-oot of the nose showed that the frontal
simas was entirely absent, the position usually occupied by it being
entirely taken up by the frontal lobes. A small opening existed on
the right side between the skull and the nose. There were the usual
indications of meningo-encephalitis, and the patient died in twenty-
four hours.
At the post-mortem, examination of the base of the skull revealed
the existence of two holes. The first, hardly perceptible, was
situated in the dura mater, beside the apophysis crista galli, and
more than 3 centimetres behind the nasal spine. It was probably
through this small slit that the flow of liquid used to take place.
The second opening was much further forward in the neighbourhood
of the foramen caecum, and 2 millimetres behind the posterior sur-
face of the bony wall, or 11 millimetres from the nasal spine, and at
least 1 centimetre in front of the lamina cribrosa, which had not
been injured. No trace of a frontal sinus was to be found either on
the right or the left side. The brain showed no sign of traumatism.
At the base, ax'ound the optic chiasma and cerebellum, there was a
considerable quantity of pus in the subarachnoid spaces, otherwise
the base of the brain showed no sign of inflammation. On the right
a focus of softening of the point of the frontal lobe invaded the two
first frontal convolutions. The ventricles were very dilated and occu-
pied with purulent serum ; the ependyma was very injected and
opaque. On the right the first frontal presented on section some
small haemorrhages in the white matter ; the centre of softening
only concerned the grey matter.
The autopsy gives no explanation of the right frontal
headache ; evidently, since there was no frontal sinus, the
CASE BY MERMOD.
37
liquid could not be anything but cerebro-spinal fluid whicli
collected between the frontal lobe and the dura mater,
escaping at intervals.
The whole profession must feel extremely indebted to
Dr. G. Mermod for his full publication of this most
instructive case. In the clinical record only one detail
is missing, viz. the analysis of the fluid, and it was only
the force of circumstances which prevented this. I
cannot refrain from directing attention to some of the most
important points in the above case, before passing on to
consider the cases together. It shows how a skilled
specialist may be misled by reference to only one or two
similar cases of a condition of which there is not an
established " Krankheitsbild." The example of Tillaux^s
case (p. 24) did not appear to Mermod to be analogous
to the above, because in Tillaux's the flow was incessant
and varied according to the position of the head ; but my
conclusions will point out that cerebro-spinal rhinorrhoea
may be constant or intermittent, and that tlie flow may
vary or be the same in different positions of the head.
Again, a too close analogy with the description of the
case of Lichtwitz (p. 64) helped to mislead Mermod, but
when I come to consider that case I will have to point
out that it is extremely probable that it also was one of
discharge of cerebro-spinal fluid.
The importance of Mermod's observation will, I trust,
excuse me for diverging to call attention to two practical
lessons it teaches. One is, that the escape of clear watery
fluid from the nose should (in the absence of gross lesions)
always raise the suspicion that it may be cerebro-spinal
fluid ; and the other is, that it may be a dangerous pro-
ceeding to attempt to penetrate the frontal sinus from the
nasal cavity.
My own case would, in chronological order, rank here
as No. VII.
The following has been published since my patient was
shown to the Laryngological Society.
38
THE CEREBRO-SPINAL FLUID.
Case VIII. — Scheppegrell. " Case of Recurrent Head-
ache, each attack being relieved by the discharge
through the Right Nostril of a Fluid from the Cranial
Cavity.^' ' Journ. Americ. Med. Assoc./ February 26th,
1898, p. 480.
In February, 1885, the patient, a female, suffered from a most
agonising headache, the pain at times being so severe that she was
entirely oblivious of her surroundings. This continued for three
weeks, and was relieved by the following accident. While descending
a stair the patient fell down a considerable distance, her head striking
against a stone jar at the bottom of the staircase. The fall was so
severe that the patient was unconscious for several seconds, but when
she revived she observed that there had been a profuse discharge of
a yellow watei-y fluid from the nostrils, and that the headache, which
had persisted for three weeks, had entirely disappeared. The attacks,
however, continued to recur at varying intervals, the intermissions
being sometimes only twenty-four hours, and rarely more than two
weeks. The headaches persisted from three to five days, and some-
times as long as ten days. On each occasion the headache termi-
nated with a spontaneous discharge from the nosti ils, principally
from the right side, and complete relief. This train of symptoms
still continued when the patient presented herself to the author in
January, 1893. She then " stated that when these headaches
commenced there was a feeling of stiffness in the neck near the
collar-bone ; then the pain seemed to ascend until it formed a focus
in the upper part of the head near the crown, and produced a
sensation as if a boil were forming, the pain extending over the
whole upper part of the head, and her eyes could be kept open only
with difficulty. The face is flushed, but there is no elevation of
temperature. An ophthalmoscopic examination gave negative
results, and there was no exophthalmos."
The right sphenoidal sinus was punctured, but no fluid escaped.
The right frontal sinus was opened externally under chloroform,
and found to be healthy. The ethmoidal cells were opened without
benefit, and the antrum of Highmore was catheterised without
giving relief.
The various accessory sinuses having now been excluded, the view
was entertained that the discharge came from the cranial cavity.
Some of it was thei-efore collected for examination. " The fluid had
a specific gravity of 1005, and was slightly alkaline in reaction, and
contained a small amount of albumen. Chemically the liquid
resembled the cerebro-spinal fluid, and the contents of the cranial
lymphatic vessels in this region, which are almost identical in
CASE BY SCHEPPEGRELL.
39
character. When this fluid was allowed to settle in a conical glass,
there was a heavy white deposit ; and the clear supernatant fluid
was of a pale straw colour, and did not coagulate. The sediment
consisted almost entirely of pavement epithelial cells, some occurring
singly, and others in flakes. A few red corpuscles were seen. In a
second specimen sent for examination, the admixture of blood was
so large that it imparted a reddish tinge to the whole body of the
liquid."
The author concludes that the fluid, which had caused the first
attack of cephalalgia, had accumulated in the cranial cavity, and
that the fall had been instrumental in breaking through the barrier
which had existed between the liquid and the nasal cavity. But if
this fluid were discharged from the subarachnoid space, it was
difficult to understand why the same quantity came from the
nostrils after each attack, and also why the discharge ceased so
abruptly, and did not continue to drip for some time after the
first pressure had been relieved. This leads the author to suppose
that this peculiarity was due to a cyst connected with the lymphatic
circulation in this region, possibly caused by occlusion of the eff'erent
lymphatic vessel of the perivascular lymphatics surrounding the vein
which passes from the nose, through the foramen caecum, to the
superior longitudinal sinus. " The location of such a cyst in this
region would not only cause ail the disturbances due to pressure
in the subarachnoid space, but would also explain the limited
amount of fluid which was discharged after each attack. The
slight admixture of blood-corpuscles evidently came from the
ruptured point in the upper part of the nasal cavity." Repeated
examination has not shown any cyst protruding into the nostril.
The above case varies in many particulars from those
we have already considered. The details of the chemical
analysis are not sufficient, by themselves, to determine
the cerebro- spinal character of the fluid, and the author
still holds the older views of chemical physiologists that
cerebro -spinal fluid and lymph are almost identical in
character. Later on I shall point out that this opinion
has been abandoned. So far as it goes, however, the
analysis of the fluid is not opposed to the claim of the
author that the fluid came from the cranial cavity,
and his diagnosis is fully borne out by the particulars
of the case. The chief point in which it differs from
the other seven cases is in the cessation of the flow
after a limited amount (mentioned to be about an ounce)
40
THE CEREBRO-SPINAL FLUID.
had escaped. As the freedom from headache — and from
the nasal discharge — sometimes endured for periods of two
to six weeksj it is to be presumed that a certain amount of
liquid had to accumulate, sometimes slowly, before it
induced headache. The author's suggestion as to how
this took place is ingenious and plausible.
The following case has only been published since this
work was written. It has, however, come to my notice in
time to inti'oduce it here before my manuscript was sent
to the printer.
Case IX. — Koener (Rostock). "Flow of Cerebro-spinal
fluid through the Nose with Optic Atrophy, a combi-
nation of symptoms probably caused by a tumour of
the pituitary body breaking into the sphenoidal
sinus." ' Zeitschrift fiir Ohrenheilkunde,' Bd. xxxiii.
Heft 1, Juli, 1898.
The patient was a female aged 37, and came to the clinic on April
8th, 1896. Since the age of ten she had been deformed, and for the
last eight years her gait had been weak and trembling. For some
years the weakness of her eyes and hands had prevented her from
working as a seamstress. About four months ago, after cough and
sneezing, she began to suffer from a flow of clear watery fluid from
the left nostril. This flow continued day and night uninterruptedly.
When lying on her back the fluid ran into her throat and was
swallowed. She is seen to be small and thin. She has a marked
kyphoscoliosis.
Her mental capacities are small; she laughs much without reason,
but to simple questions she gives clear and correct answers. As a
rule she sits still and holds a handkerchief or a glass beneath her
dripping nose. She cannot walk alone without assistance, and has
to steady herself against the nearest object. Her movements are
not ataxic; it appears rather as if she had a great weakness in her
legs.
From the left nostril there drops incessantly a clear watery fluid.
On different occasions this was collected, and each time it averaged
about 15 c.c. per hour. On analysis, Professor Nasse found 1"18
per cent, of fixed matters and 0 75 per cent, of ash. The loss on
ignition (Gliihverlust) (0'43 per cent.) was reckoned chiefly as
albumen. On account of the scantiness of the fluid the mucin
could not be reckoned with certainty ; the ash contained much
CASE BY KORNER.
41
NaCl. In the right side of the nose nothing abnormal was dis-
coverable. In the left side there was a considerable hypertrophy
of the anterior end of the middle turbinal.
As regards the eyes, there was slight prominence of the eyeball
and rotary nystagmus. The right pupil was normally dilated, the
left somewhat wider. The right pupil reacted well to light, but the
left did not react at all to direct light, although it did so decidedly
for accommodation. There was slight insufficiency of both internal
recti. The vision on the right was f ; on the left, fingers could
only be counted when held close to the eyes. On both sides thei'e
was decided optic nerve atrophy.
There was no enlargement of the thyroid gland; no signs of
acromegaly. It was thought that the patellar reflexes and skin
sensibility were normal, but there was no note of it in the case
book. The patient was only a short time under observation; she
returned home and died four and a half months after the above
observations were made. The nasal flow continued up to her death.
There was no autopsy.
The source of the fluid had not been recognised while the patient
was undv'ir observation, and hence the observations taken were not
as complete as might be desired. The hypertrophy of the middle
turbinal was removed without altering the flow ; the portion removed
was found to be an ordinary hypertrophy. The left maxillary sinus
was punctured, but no fluid was discovered in it. It was only when
the author became acquainted with the case of Gutsche {vide p. 33)
that he realised that in the above case he had had to do with an escape
of cerebro-spinal fluid, and he concludes that in his own case, as in
Gutsche's, it was due to a tumour of the pituitary body. He has
collected the records of eight cases wLich have been published ot
optic nerve atrophy with escape of watery fluid from the nose, and
suggests that in all of them both these symptoms were due to a
tumour of the pituitary body. These eight cases are those of
Baxter (p. 56), Gutsche (p. 33), Hardie and Wood ('New York
Med. Journ.,' 1890, vol. ii, September 6th, p. 264), Leber (p. 26),
Nettleship (p. 57), Priestley Smith (p. 59), and Wallace Mackenzie
(p. 31).
Although the chemical analysis is incomplete in tbe
above case, yet the physical characters of the flow, its
limitation to one side, its continuity night and day, the
amount discharged per hour, its association with optic
nerve atrophy, and the negative examination of the nasal
fossae and their accessory cavities, are sufficient evidence as
to the arachnoid origin of the fluid. I cannot agree with
42
THE CEEEBRO-SPINAL FLUID.
Korner's suggestion that in all the cases he quotes the
escape of cerebro-spinal fluid was due to a tumour of the
pituitary body breaking through into the sphenoidal sinus.
In Baxter's case no such tumour was discoverable at the
post-mortem. A study of the case of Hardie and Wood has
convinced me that it was one of vaso-motor rhinitis. In
Nettleship's case the flow ceased. And in Priestley Smith's
the flow lasted from two to four years, which it would
hardly have done with a progressive growth at the base
of the brain.
To facilitate reference and comparison the main points
in these nine cases may be recorded in tabular fashion
[vide Table A).
TABLE A.
44
THE CEREBRO-SPINAL FLUID.
Table A. — Cases in which the Discharge from
No.
Author,
reference.
Sex
and
age.
Duratiou.
Cerebral symptoms.
Eye Bymptoms.
General.
I
luiaux,
Traite
d'Anatomif
Topo-
graphique,
1877
M.,
adult
iNot or
recent
date."
Under ob-
servation
10 months
Some headache
from time to time,
but enjoyed all his
faculties. Death
with convulsive
symptoms
Flow continuous,
increasing on
bending head for-
ward, and ceasing
in horizontal
position
11
Leber,
Arcbiv f .
Ophthal-
mologie,
xxix, 1883
20
Com-
menced at
age of 20
Hydrocephalus
from birtli.
Intelligence good
in childhood.
With railure of
vision came onset
)f giddiness, severe
headache, and
epileptic seizures
Vision good in
childhood. At
age of 15 failure
of vision from
post-neuritic
atrophy
Continuous flow,
but with intermis-
sions of periods of
8 days to 4 weeks ;
increased on bend-
ing head forward;
during sleep not
noticed, probably
because the fluid
flowed backwards
III
Toison and
Lenoble,
Comptes
Rendus de
la Societe
de Biologie,
tome iii,
serie 9,
1891
F.,
28
4 months
Onset sudden
IV
Wallace
Mackenzie,
Trans.
Intercol.
Med. Con-
gress, Third
Session,
1892, p. 500
M.,
20
2 years
Severe headache at
age of 17, with sort
of fainting fits ; no
convulsions. These
ceased with the
establishment of
the nasal discharge
at age of 18, and
had not returned
during the two
subsequent years
Gradual failure
of vision com-
menced at age of
17, with well-
marked double
optic neuritis.
At age of 20
atrophy of both
optic discs ; no
retinal haemor-
rhages
Well nourished,
healthy looking,
intelligent
TABLE A.
45
! Nose ivas undouhtedly Cerehro-spinal Fluid,
Nostril affected,
ccessory cavities.
History.
Previously twice
operated on for
nasal polypi
ft. Botli nasal
fosste free
Progress and
results.
Quantity and character
of fluid.
Violent fall 4
years previously
Left; no nasal
3lypi; no disease
n nose, accessory
cavities, or naso-
pharynx
Variations in the
flow of the liquid,
which even ceased
at times for several
months without
treatment. Death
Headache and
giddiness ceased
when flow was
estahlished. Con-
vulsive seizures
continued, and
were not more apt
to occur during
periods of arrested
dropping
i litre in the day.
Analysed hy
M. Mehu, who
reported that it
was pure cerehro-
spinal fluid
Fluctuated be-
tween 4 c.c. and
22 c.c. per hour;
76 c.c. escaped in
6 hours. Full
analysis given ;
clear, free from
odour, alkaline ;
sp.gr. 1007-8;
no albumin
75 c.c. in 6 hours,
or 300 c.c. in 24
hours ; but on
another occasion
only 186 c.c. in 24
hours. Very full
analysis given ;
absence of odour
and colour ; sp. gr.
1007; presence of
a reducing body
Flowed at rate of
1 ounce an hour;
clear, transparent ;
sp. gr. 1006 ; no
sugar reactiou
Cerebro-spinal
rhinorrhoea.
Cerebro-spinal
rhinorrhoea.
Cerebro-spinal
rhinorrhoea
Cerebro-spinal
rhinorrhoea.
46*
THE CEREBRO-SPINAL FLUID.
No.
Autlior,
reference.
Sex
and
age.
Duration.
Cerebral symptoms.
Eye symptoms.
General.
—
V
uutscne,
Centralb. f.
Laryngo-
logie, xi,
1895
M.,
34
58 days
Death from
cerebro-spinal
meningitis
Otherwise in
perfect health.
When lying down
flow passed into
throat
VI
Mermod,
Annales des
Mai. de
I'Oreille et
du Larynx,
tome xxii,
No. 4, 1896
M.,
36
Several
years
Headache and
heaviness, most
severe on right side,
and always relieved
after abundant flow
of clear liquid.
Death from
meningo-encepha-
litis following
exploration
No ocular dis-
turbance; vision
equal on both
sides; papilla
clearly defined
VII
StClair
Thomson,
The Cere-
bro-Spinal
Fluid,
London,
1899
25
5 years
Headache since
childhood, but
absent since nasal
flow was estab-
lished; returning
slightly during
cessation of flow
Eyesight
unaffected; no
trace of optic
atrophy or
retinitis
General health
good
VIII
Scheppe-
grelljJourn.
Amer. Med.
Assoc.,
Feb. 26th,
1898
F.
8 years
Intense headache;
eyes kept open
with difficulty;
always relieved by
flow
Ophthalmo-
scopic
examination
negative; no
exophthalmos
Presumably good
IX
Korner
(Kostock),
Zeits. f .
Ohren-
heilk.,
Bd. xxxiii.
Heft 1,
Juli, 1898
F.
9^ mouths
Limited mental
capacities
Slight promi-
nence ; rotatory
nystagmus ;
right pupil
normal, and re-
acted; left
larger, and re-
acted to acom-
modation, but
not to light ;
marked optic
nerve atrophy
both sides, worse
left
Small, thin ;
marked kypho-
scoliosis; not
ataxic, but cannot
walk without
assistance
TABLE A,
47
Nostril affected.
\ecessory cavities.
Left
Both nostrils ;
lasal polypi and
hypertrophic
linitis ; empyema
of maxillary
ntrum and ante
or ethmoidal cells
n right side, and
left sphenoidal
Left ; nose,
ccessory sinuses,
nd naso-pharyn.\
normal ; no
leezing or irrita^
tion ; no loss of
smell
light; accessory
cavities on right
iide all shown to
be healthy
Left
History.
No history of
accident
Headache
after lasting
3 weeks relieved
by flow from
nose, consequent
on a fall
Trembling and
weakness of gait
preceded nasal
How by 8 years ;
weakness of
hands and eyes
for some years
previously
Progress and
results.
Quantity and charactei
ol fluid.
Death. Post-
mortem
Flow intermittent.
Death. Post-
mortem
Four intermis-
sions of 1 to 2
months' duration ;
otherwise con-
tinuous day and
night
Flow ceased after
iiu ounce escaped ;
recurred every 24
hours to 2 weeks,
as conclusion to a
headache
Nothing found in
nose or left
maxillary antrum
to account for
flow
250 c.c. in a day ;
clear, rich in albu-
men ; contained a
[•educing substance
which was not
sugar
Clear as water.
No analysis
Diagnosis.
Cerebro- spinal
rhinorrhoea.
During life, a
cyst of right
frontal sinus.
From the
autopsy,
cerebro-spinal
rhinorrhoea.
Cerebro-spinal
rhinorrhoea.
15 ounces to
561-6 c.c. in 21.
hours. All the
characteristics of
cerebro-spinal
fluid
Watery, 1005, Cerebro-spinal
slightly alkaline; rhinorrhoea
small amount of
albumin
Clear watery fluid, Not diagnosed
averaging 15 c.c. while under
per hour; 1'18 per observation.
cent, of fixed | On becoming
matters, and 0 75 acquainted with
per cent, of ash Gutsche's case
(No. V) Korner
concluded that
the flow had
been cerebro-
spinal fluid.
48
THE CEREBEO-SPINAL FLUID.
Summary op Undoubted Cases op Cerebeo-sptnai.
Rhinorrhcea.
From these nine cases the following points may be
summarised :
Females 5, males 4 ; therefore both sexes appear to be
pretty equally affected.
Age from 20 to 37 ; therefore an affection of youth
and adult middle life.
Cerebral symptoms in
Eye symptoms in .
Side of the nose affected mentioned in
From left side in
From right side in
From both sides in
Intermission in the flow occurred in .
not mentioned
8 cases.
3 „
7 „
5 „
1 case.
1 „
5 cases.
Continuous flow, day and night pre-
sumably, in .
Not noticed at night
No note in .
Complete disappearance of the flow in
Death in .
with cerebral lesions in
Post-mortem in .
4
1 case.
4 cases,
no case.
4 cases.
3 „
2
The first autopsy showed swelling of pituitary body
and of the chiasma nervorum opticornm, empyema of the
sphenoidal sinuses and of the left maxillary antrum, and
arachnitis purulenta.
The second autopsy showed that the escape of cerebro-
spinal fluid had occurred through a hardly perceptible
hole beside the apophysis crista galli.
We now come to the cases collected from other
observers, which I have placed together in a second
group and entitled Most probably cases of cerebro-
spinal rhinorrhcea," although their authors have re-
CASE BY KING.
49
corded them under various headings. Several of them
have already been claimed by Leber ^ as being what I
esteem them to be, and Wallace Mackenzie ^ expresses his
opinion that in six of them the fluid came from the same
source as in his own case, viz. the subarachnoid space.
In all, I have collected twelve cases in which the proof
of the cerebral origin of the fluid is not positively certain ;
and although I am of opinion that the balance of evidence
would justify their inclusion with the first nine cases, I
have thought their consideration would be facilitated by
placing them together in this second and slightly doubt-
ful group.
Group B. — Cases in which the Discharge from the Nose was
most probably Cerebro- spinal Fluid.
In chronological order.
Case X. — King. ' The London Medical and Surgical
Journal,' vol. iv, 1834, p. 823.
At the Westminster Medical Society on Saturday, January IStli,
1834, " Mr. King related a case whicli had occurred to Mr. Rees, ot
Finsbury Square, who had transmitted the notes to him. A female
aged 52 had excessive discharge of clear limpid fluid from the left
nostril, to the amount of a quart in twenty-four hours. It had
commenced three months before, and was constantly secreted night
and day. It became necessary to wear a sponge for the purpose of
absorbing the discharge, as, from its constant trickling into the
larynx, it had several times threatened suffocation. The patient is
stout, but subject to excessive action of the sanguiferous system ;
her eyelids are puffed ; there is a florid state of the countenance,
and a pulse of 96. She has a general disposition to anasarca, and
the catamenial discharge, which appeared at ten years of age, and
which has continued to flow ever since, is quite regular. Her diet
consists of vegetables. Hitherto no local or general treatment has
been found of avail."
^ Loc. ext.
2 ' Transactions of the Intercolonial Medical Congress,' Third Session, held
in Sydney in 1892, p. 500.
D
60
THE CEREBRO-SPINAL FLUID.
Case XI. — John Blliotson. "Liquid Watery Fluid in
very large quantities from the Left Nostril." ' The
Medical Times and Gazette/ 1857, New Series, vol. xv,
p. 290.
On July 19tli, 1842, Dr. Elliotson was first consulted by a lady
aged 40, in excellent general health, on account of a profuse flow of
watery fluid from her left nostril. She had had a similar attack
fourteen years previously. One night she had a severe pain in her
head, and the next day as the pain declined the left nostril began to
run, and by the evening she felt no more pain and the discharge
was at its height. It lasted eighteen months, and suddenly ceased
without obvious cause one night, after having been as profuse as
ever the day, and indeed the evening, before.
The second attack had been going on for thirteen months when
she first consulted Dr. Elliotson, The fluid was more copious than in
the first attack, and as much as three quarts had been discharged
in a day. The fluid was colourless, without odour, and so watery
that the handkerchiefs dried soft and served again without the
necessity of washing. As many as five and thirty were used in a
day. When she went to bed a number of towels were placed about
her face and neck, and when they became saturated she always
awoke from their wetness and coldness. She was compelled to
sleep nearly upright. There was no sneezing, and presumably her
sense of smell was unaflfected. If she stooped, the fluid streamed
from her nose. She felt no thirst, and drank little more than in
health. All her secretions and functions were undisturbed. Pulse
80 and good. All causes of debility, excitement, heat, and especi-
ally damp, aggravated the complaint. During the two attacks she
occasionally had a cold in her head like other people, and lost her
voice and sense of smell, and discharged thick opaque mucus from
both nostrils, as is usual in catai-rh ; but then the limijid watery
fluid continued to drop from the left nostril just as when she had no
cold.
This second attack had arisen from no evident exciting cause,
had not been preceded or attended by headache, had increased
slowly, and arrived at its height in fourteen days. The treatment
to which she had been subjected in the first attack was, as Dr.
Elliotson justly says, " terrific." " It consisted of repeated very
copious bleedings in the arms, cuppings, leeches to the nose, blister-
ing behind the ears, each pair of blisters being kept open for a
week, strong purgatives, fruitless attempts at salivation by mercury,
saline draughts, and low diet." During the second attack she was
treated with tannin and gallic acid in increasing doses, and secale
CASE BY PAGET.
51
cornutum, but witliout benefit. She then consulted Sir Benjamin
Brodie, who prescribed a grain of sulpbate of zinc with 3 grains of
extract of sarsaparilla three times a day, and an injection of 20 grains
of sulphate of zinc and 1^ drachms of tincture of galls in 8 oz. of
water. Three weeks after this prescription was begun the discharge
declined a little, and it slowly lessened till it ceased entirely in
about three months.
Hence the first attack ceased spontaneously at the end of eighteen
months; the second under treatment at the end of twenty-three
months. The fii-st began suddenly and ended suddenly ; the second
took place slowly and declined slowly. Elliotson doubts whether
the prescription effected the cure.
When free from her complaint she required much less stimulant.
Instead of drinking eight or nine glasses of wine a day, three or
four glasses produced just the same comfort. She was free from
recurrence at the date of publication, i e. fourteen years afterwards,
although in the meantime she is reported by Dr. Elliotson to have
sufi'ered from dropsy of the right ovary, a condition which was
cured by mesmerism.
The following analysis of the fluid is given :
The limpid character of the watery fluid and its low-
specific gravity point towards cerebro-spinal fluid ; the
rest of the analysis does not help towards any conclusion.
Case XII. — Sir James Paget. ^' A Case of Polypi of
the Antrum in which "Watery Fluid dropped from
the Nostril." ' Transactions of the Clinical Society/
vol. xii, 1879, p. 43. Read November 22nd, 1878.
The debate is given in the ' Medical Press/ 1878,
vol. xxvi, p. 432, and in the 'British Medical Journal/
1878, vol. ii, p. 836.
The patient was a lady 49 years of age, robust and healthy
looking, and with no signs of general ill-health, or any appearance
of disease in the nostrils. There was nothing like polypus or un-
Specific gravity
Water ....
Mucus ....
Chloride of sodium
Sulphate of soda
Soda combined with mucus .
Traces of lime and phosphoric acid.
1010
98-885
•104.
52
THE CEREBRO-SPINAL FLUID.
liealthy membrane, or swelling as of a cyst ; no nasal obstruction or
unusual flow of tears, no swelling or tenderness, and nothing to
indicate the source of tbe fluid. The sense of smell was perfect.
The secretion never was purulent. This fluid had been di'opping
from the left nostril, with rare intermissions, for eighteen months.
As to her history, it was insignificant. In November, 1876, she
received a heavy blow over the left frontal sinus, but it seemed to
have done no harm at the time. In January, 1877, she had for one
day a severe headache, such as she had never had before or since.
In February she had a severe mental shock, and in May, 1877, the
dropping began. From that time it had continued up to the date
of publication (November 22nd, 1878). Once, in May, 1878, it
ceased for a fortnight, when she had bronchitis and took morphia ;
and once it ceased in the night. It always flowed from the left
n9stril. The amount was variously calculated at " a drop every five
or six seconds ; " " four ounces were once collected for me in the
course of an afternoon and evening;" and "at the rate of 314
grains in twenty minutes." The quantity was generally nearly
uniform, but it was always increased by mental distress or by much
exertion, or by straining. At night much of it collects in the
nostril and is poured out when the posture of the head is changed.
Not a drop has ever come from the right nostril, unless when the
left nostril and upper part of the pharynx has become filled
with fluid during sleep at night; and then, on turning the head
downwards and to the right, the fluid pours through both nostrils.
The fluid looked like pure water, or like the fluid of the pia mater
or that of an acephalocyst.' On standing, the slight greyish deposit
showed only some granular and molecular matter and a few epi-
thelial cells and a few round cells. One analysis reported as
follows : — " 100 parts of the liquid contains 1'15 of solid matter
in solution, consisting of —
0"965 inorganic matter
0'189 organic „
1-154
The liquid is slightly alkaline; it contains proteid matter, probably
albumen, and there is no indication of grape-sugar in it. The solid
residue is probably chloride of sodium, but it contains phosphates
and, I think, iron" (Dr. Russell). In another specimen, including
a large proportion of fluid which had accumulated in the nosti-il
and above the palate during sleep, the specific gravity was 1"004,
and the quantity of debris much larger. An analysis made by
1 In describing the fluid from his undoubted case of cerebro-spinal rhinor-
rhcea, Tilliiux remarks, "Ce liquide est parfaitement clair et limpide comme
de I'eau de roche; 11 rappelle tout a fait le liquide des kystes liydatiques."
CASE BY PAGET.
53
Mr. Thomas Taylor, one year previously, showed that the specific
gravity of one specimen was 1009'3, of another 1010'44. The dry
solid matter obtained from 100 fluid grains of the former was 1"2
grains of the latter 1'26. The solid matter consisted of albumin
0 05, other animal matter 0'48, chloride of sodium 0*78, with traces
of carbonate of soda and phosphoric acid.
Sir James Paget expressed the opinion, though speaking with
much doubt, that the fluid was derived either from a frontal or
ethmoidal sinus, or from the subarachnoid space or the sac of the
arachnoid membrane. He thought, however, that it was doubtful,
and even improbable, that the fluid was cerebro-spinal, and it was
certainly not a catarrhal affection.
Mr. Lawson, who had seen the case, believed that it was cerebro-
spinal fluid which escaped. He remarked that during sleep very
little came away, and appositely asked, " Was this because less was
then secreted, or only because the fluid was swallowed ? "
Some time afterwards, when Paget's attention had been drawn to
the result obtained by Sir Benjamin Bi-odie in Case XI, the
patient was given one grain of sulphate of zinc three times a day,
increasing that dose gradually to twice the quantity, while the
nostril was injected three times a day with a solution of three grains
of the sulphate of zinc in an ounce of water. This plan was steadily
followed for about six weeks, then the dropping of fluid gradually
diminished, and in two or three weeks more completely ceased. The
patient remained well and active and free from all discomfort till a
month after the cessation of the dropping. Then, after exposure to
mental distress, fatigue, and cold, she was seized with headache,
vomiting, restless delirium ; "her pupils were contracted ; and after
this, with signs of acute brain disease becoming gradually more
intense, she died comatose three days after the beginning of her
illness."
At the post-mortem there were symptoms of diffuse meningitis,
" and over large portions of the anteiior cerebral lobes, and some
parts of the base of the brain and of the cerebellum, the pia mater was
almost symmetrically infiltrated with pale greenish-yellow, soft
lymph. The whole base of the skull, the cribriform plates of the
ethmoid bone, the olfactory bulbs and the dura mater in relation
with these, were completely healthy. The examination was made
the more carefully because of a suspicion that it might have been
subarachnoid fluid which had dropped from the nostril. Nothing
in evidence of such a supposition could be found. The lining of all
the nasal cavities and sinuses, except that of the left anti'um,
appeared quite healthy. Of this antrum the bony walls were un-
changed ; its shape and size were natural, and nothing external
indicated any change within. But its floor was covered with two
broad-based convex polypoid growths, deep clear yellow with the
54
THE CEREBRO-SPINAL FLUID.
fluid infilti'ated in their tender tissue, and covered with exceedingly
thin smooth membrane traversed by branching blood-vessels. They
were of rounded shapes, about two thirds of an inch in diameter and
half an inch in depth; they looked like very thin- walled cysts, but
were formed of very fine membranous or filamentous tissue in-
filtrated with serum. On the outer wall of the antrum were
flattened soft yellow masses, which appeared the residue of one or
more similar polypoid bodies collapsed after breaking or accidental
injury and the escape of the greater part of the serous fluid." (The
specimen is in the museum of the College of Surgeons.) The author
concludes that this copious production, whether by secretion or
filtration, of a fluid of less specific gravity than any produced either
naturally or in disease — unless it be the subarachnoid fluid — was
brought about by these polypi in the antrum. He refers to the
publications of Giraldes, Luschka, and Virchow on the disease,
and observes that neither in these nor in any other v/orks has he
been able to find mention of the dropping of fluid from the nostril
as one of the signs of either cysts or polypi in the antrum. No con-
jecture is hazarded as to the cause of the fatal meningitis.
The physical characters of the liquid and its low
specific gravity indicate cerebro-spinal fluid ; the analysis
shows nothing to oppose this conclusion.
Case XIII. — H. Fischer. " Wasserige Ausscheidungen
aus einer Nasenoffnung.^^ ' Deutsche Zeitschrift fiir
Chirurgie/ 1880, Bd. xii, S. 369.
" A man aged 42 was in hospital because of a broken leg. The
patient was otherwise perfectly healthy, but had sufi'ered from
headaches. One morning, without any apparent cause, a dripping
of a turbid watery fluid like thin milk began to flow out of his left
nostril, and lasted for several hours. It dripped drop by di'op as in
bleeding of the nose. When I saw the patient the dropping had
already stopped. The quantity which escaped amounted to 200
grammes; it had a specific gravity of 1003, and an alkaline reac-
tion. The chemical examination showed slight traces of albumin,
chloride of sodium, and phosphates ; under the microscope the fluid
revealed no formed elements, especially no booklets of echinococcus.
The patient stated that he had this phenomenon for the third time,
and that each time after it his headache was always relieved.
"Although thei-e was no outward sign of disease of the sinus
fi'ontalis, I nevertheless thought it well to accept hydrops of the
CASE BY SPEIES.
55
same, whicli emptied itself periodically. He had no neuralgia of
the fifth nerve such as Althaus demonstrated in his case (' Brit.
Med. Joum.,' December 7th, 1878)." A similar observation to the
above was demonstrated by Paget to the Clinical Society on the
22nd November, 1878.
Tlie analysis does not contradict tlie conclusion that
the fluid was of cerebro-spinal origin. The descriptions
of the fluid as being " turbid " and like thin milk ^' do
not of course support such an idea^ but this appearance
might have been brought about by admixture.
Case XIV. — W. R, Speies. "Notes of a Case in which
the Principal Symptom was a Constant and Copious
Watery Discharge of Watery Fluid from the Nose.^'
' Lancet/ March 5th, 1881, p. 369.
A man aged 55 had sniFered from a constant dropping of a clear
watery fluid from the nose. It commenced at first with sneezing,
and he was inclined to attribute it to the irritation arising from his
occupation as a tailor. Change of work, however, made no dif-
ference. There was no history of injury, and there was neither
pain nor swelling at any time during the continuance of the flow.
The fluid came drop by drop, but at times almost so quickly as to
foi'm a stream; an ounce was easily collected in a quarter of an
hour, and at times the flow was so copious that any garment he was
making became completely sattii'ated in a very short time. The
specific gravity of the fluid was not noted, but it was perfectly clear
and colourless, free from smell, and, according to the patient, had
no taste. It contained no albumin, and a handkerchief saturated
with it did not stiff'en on drying. It did not excoriate the upper
lip. At night the patient was compelled to have his head raised
till he was almost in a sitting postui'e, as when lying down the fluid
ran back into his throat and caused a choking sensation. Exercise
in the open air seemed to lessen the discharge. The sense of smell
was unimpaired. "There was no appearance of disease in the
mucous membrane of the nosti-il, and nothing whatever to indicate
the source of the fluid." Local treatment with glycerine of tannin,
tannic acid in powder, and vai'ious other astringents, and general
treatment with purgatives, liquid extract of ergot, and liquor
strychnise, produced no decided variation in quantity. The patient
himself experimentally adopted the plan of keeping his nostrils
filled with goose grease, and the dropping gradually ceased day by
56
THE CEREBRO-SPINAL FLUID.
day, until within a week it had quite disappeared, after lasting for
nine months. Speirs considers that the post-mortem of Sir James
Paget's case proved that the fluid came from the antrum, and pre-
suming that his case was identical he suggests that the goose
grease may have filled up the fissure of communication between the
antrum and middle meatus of the nose, and thereby so altered the
existing condition of the structure lining that cavity as to eflFect a
cessation of the excessive secretion.
Case XV.—E. B. Baxtee. - A case of Paroxysmal Clonic
Spasm of the Left Rectus Abdominis, with Symptoms
pointing to the Existence of Gross Intra-cranial Dis-
ease." 'Brain/ vol. iv, January, 1882, p. 525.
Although the nasal condition is not mentioned in the title of this
paper, it was for a nasal discharge associated with "nervous
io-,n ^""i ^ ^^^^ ^^^"^ consulted Dr. Baxter on November
IStn, 1879. It appeared that in November, 1877, after a good deal
01 wori-y and anxiety, she began to sufi^er from headaches and
twitches (as she termed them), and shortly after these symptoms
made their appearance, a clear watery fluid, sometimes rather off-en-
sive, occasionally tinged with blood, began to come from the right
nostril. The twitchings occurred almost daily, lasting from ten
minutes to a couple of hours. They were due to a violent recurrent
spasm of the left rectus abdominis, and were followed by symptoms
like those of ordinary hysteria. The headaches, which were most
severe, also occurred almost daily. The pain began at the root of
the nose, spread round to the back of the head, and there was a
constant fixed pain on the left side of the occiput. The pains were
not at all periodic; they occurred almost daily, were worse during
the day, and never kept her awake at night.
No relation is indicated between the headaches and the discharge
from the right nostril. The right nostril was pervious. No ulcera-
tion or disease of bone conld be detected by examining with the
rhinoscope or from the front. The discharge was only sometimes
offensive, and Dr. Baxter could never himself perceive any un-
pleasant odour when he saw her. The upper jaw was crowded
with decayed stumps. There was no impairment of taste or smell
Jonfusior^'" ^""^ consciousness or intellectual
nZ-H^'.^^.T.'^^Jr i^q^ired into, she
admitted that it had been failing for some three weeks. The pupils
were found to be equal and to react well ; no squint ; incomplete but
CASE BY NETTLESHIP.
57
decided hemiopia. Shortly afterwards Mr, Nettleship reported —
R
" v. — ■ 7 Jager, oo i|. Colour perception normal. Upper and
outer quadrant of eacli f. v, either foggy or quite a blank. Neuritis
of moderate intensity in either eye."
Soft uniform hypertrophy of the thyroid body was first noticed
two years ago, when the present illness began. Pulse 104, regular.
Nothing amiss with heart, lungs, or urine.
Her eyesight continued to fail nearly to blindness. Headaches
and vomiting attacks increased. Other symptoms (nasal discharge,
thyroid enlargement) vinabated. She grew thinner and weaker, but
her intellect remained unaffected until three days before her death,
when she had convulsions and coma, and died on January 29th,
1881, i. e. about three and a half years after her illness began.
At the post-mortem the bones of the skull appeared to be thicker
and more dense in texture than usual ; but nothing in any way
abnormal was discovered in the intei'ior of the skull, the brain, or its
membranes. The cavities of the sphenoid and ethmoid were opened
without finding any evidence of disease ; but the autopsy appears
to have been imperfect.
The author remarks that " the negative result of the inspection
was a surprise to me. The experience of others may, perhaps, con-
tribute to the explanation of what remains to me inexplicable."
I would note in this record^ that although the patient
at times complained of the oJffensiveness of the discharge,
it was not to be detected by the observer, and was only
occasional. With the exception of the statement that it
was " clear and watery " and occasionally tinged with
blood, we have no full description of the fluid. There is
no information as to its flowing, and no relation indicated
between the flow and the headaches.
Case XVI. — Edward Nettleship. " Case of Optic Neuritis
followed by Dropping of Fluid from the Nostril.''
'The Ophthalmic Review,' vol. ii, 1883, p. 1. A paper
read at the Worcester meeting of the British Medical
Association, August, 1882.
An intelligent girl with somewhat pi-ominent eyes, but of healthy
appearance, aged 23, first came to St. Thomas's Hospital in Novem-
ber, 1881. About two years pi'eviously she was ill with palpitation
58
THE CEREBRO-SPINAL FLDID.
and hysterical fits, and is said to have lost her senses. She
recovered from this, but six months later she " forgot her words
and was upset in the braiu." She was confined to bed for several
weeks with much headache and pi-ostration, and was especially
enfeebled down the left side. There Avas no vomiting. During the
illness her sight failed, became very bad, and then improved up to
the state in which it was found on examination. The headache
ceased, and had not returned. Twelve to eighteen months after
the above illness her ocular condition was as follows :
L L. and 20 J. letters, not improved.
The optic discs stowed post-papillitic atrophy ; pupils large and
sluggish ; no defect of colour vision ; the visual field in each eye
was very much contracted, the left eye being more aflPected. For two
months pi'evious to this date (November 8tb, 1881) she had been
much annoyed by a profuse running of clear water entirely from the
left nostril. The fluid is said to have given no trouble when she
was in bed ; it was not obviously affected by almost total abstinence
from all fluid for a whole day, nor by a long course of ergot, nor by
a weak salt and water douche. Dr. Felix Semon examined the
patient and found the mucous membrane of the left nostril swollen
and excoriated, that of the right nostril being healthy. There was
no evidence of disease in the chest or elsewhere. The following is
the analysis made Mr. S. Plowman, the chief dispenser of St.
Thomas's Hospital : — " The fluid was colourless, but slightly ropy
and opalescent. It was neutral to test paper. It contained a con-
siderable quantity of chlorides, but only traces of phosphates and
sulphates. It contained no sugar. It gave the various proteid
reactions, and responded to the tests for mucin. No quantitative
analysis was attempted, but albumen seemed to be present in
somewhat larger quantity than mucin." It is added, " We may
probably conclude from this analysis that the fluid was derived from
the nasal cavities and was not meningeal." One year afterwards
(i. e. in October, 1882) the dripping had become less troublesome,
the sight had not altered, and the discs were still hazy. In the
German edition of Mackenzie's book on 'Diseases of the Throat and
Nose' (published in 1884) Semon writes that whence the abundant
secretion originated (30"00 in two hours) was not discoverable. He
adds that quite lately the patient again presented herself; the
rhinorrhoea had disappeared.
The chemical analysis in this case is not distinctive of
cerebro-spinal fluid. The physical characters of the
liquid and the presence of mucin and albumin are, indeed.
[R. and 4 J., improved to fg by
-ID. sph.
- 1-25 D. cyl.
CASE BY PRIESTLEY SMITH.
69
opposed to the conclusion.-^ Still it is well to bear in
mind tliat other secretions may have become mixed with
the cerebro-spinal liquid during its passage through the
nose, and that its true character might thus have been
very well overlooked without recourse to the delicate
and more exact tests which were not in use at the date of
the publication of this case. We are therefore obliged to
look to the clinical description of the case to justify its
inclusion in the present paper. The symptoms on which
I rely are the cerebral ones, the affection of the eyes, the
negative result of the examination of the nose by a skilled
observer, and the one-sidedness of " a profuse running of
clear water.'' These points will be referred to in detail
later on.
Case XYII. — Priestley Smith. Persistent Dropping of
Fluid from the Nostril, associated with Atrophy of the
Optic Nerves and other Brain Symptoms." ' The
Ophthalmic Review,' 1883, vol. ii, p. 4. (The greater
part of this paper was read at the Worcester meeting
of the British Medical Association, August, 1882.)
Case 1. A man aged 28 came under observation on February
24th, 1880. In 1875 he began to suffer severe pain in the head and
to have frequent attacks of vomiting. His sight began to fail soon
afterwai'ds, and within three or four months he was quite blind.
He remained liable to pain in the head. In 1879, i. e. four years
later, fluid began to drop fi-om the left nostril. When this had
continued about four months it diminished in quantity, and after a
week, during which time he complained of pain in the head and
drowsiness, it stopped. He slept thirty-six hours without waking,
and for nearly a week was constantly falling asleep. He then
brightened up again and the dropping returned, but through the
right nostril instead of the left. Similar attacks of drowsiness,
always preceded by arrest of the flow of the fluid, recurred from
time to time, never at longer intervals than two months. In the
later attacks he would lose consciousness and become convulsed.
1 The term albumin is frequently used by clinical observers as synonymous
with any proteid coagulable by heat, and would therefore include globulin.
There is no attempt in the above analysis to differentiate between true
albumin and globulin.— W. D. Hallibueton.
60
THE CEREBRO-SPINAL FLUID.
In December, 1881, the fluid ceased running; lie became heavy,
dull, convulsed, unconscious, and died. No post-mortem. Six
months after the dropping had begun Mr. Priestley Smith found
the right eye with faint perception of light, and the left totally
blind. In both eyes media clear and the discs atrophied, horizontal
nystagmus, the right eye making a considerably larger excursion
than the left.
A colourless clear fluid dropped from the right nostril at the rate
of about five drops per minute; collected for fifteen minutes it
measured 90 minims (equivalent to 18 fl. oz. in twenty-four hours).
No record of the result of examination of the interior of the nose,
but he could blow freely down each nostril.
The following is Dr. MacMunn's report of the fluid : — " Reaction
alkaline ; specific gravity about 1007, but the quantity too small for
precise determination ; chlorides present in abundance ; no sugar ;
it contained alkali albumen ; mucin was also present. In the spec-
troscope it gave the band of sero-lutein distinctly ; the microscope
showed some mucus corpuscles and bacteria and vibrios." To this
Dr. MacMunn added, " It is hardly necessary to say that it gave no
reaction with ferric chloride, as it could not well have been salivary.
I should be inclined to think that it probably came from the fi'ontal
sinus, as cerebro-spinal fluid is said to contain traces of sugar, or of
a substance capable of reducing cupric oxide, and this gave none.
There was one peculiai-ity about this fluid which I cannot
understand, viz. it transmitted all the blue of the specti'um violet."
Case XVIII. — Peiestley Smith. Ibid.
Case 2, Man aged 22, reported on February 17th, 1882. In 1876,
when seventeen years of age, he was in fairly good health, but over-
worked and very liable to headache. One evening he suddenly
called out, put his hand to his head, fell forward and became un-
conscious. During many months his consciousness remained more
or less imperfect, and he was at times violently delii-ious ; he had
violent pain in the head, frequent vomiting and fits; he became
totally blind. About four months after the onset the hospital notes
said, "he answers sensibly on being pressed; can turn both eyes
inwards, neither of them outwards ; the eyes jerk, especially the
left; there is double optic nem-itis passing into atrophy." For
fourteen or fifteen months afterwards he was totally paralysed in
the lower extremities, and had involuntary micturition and defaeca-
tion. Two and a half years (November, 1878) after the beginning
of the attack, and just as he was beginning to recover some power
in his legs, fluid began to drop persistently from his right nostril.
CASE BY PRIESTLEY SMITH.
61
Some months later this nostril became stopped up, and a surgeon
took something from it which he called a polypus. It soou became
stopped up again, as it is now ; and from that time until now the
dropping has been through the left nostril.
When examined by Mr. Priestley Smith on February 17th,
1882, it is reported :— His legs are weak, he cannot walk more than
a hundred yards or so. Pupils dilated ; no perception of light in
either eye ; discs atrophied ; no paralysis of any ocular muscle.
The right nostril is occluded by a polypoid growth; fluid drops
from the left. The quantity discharged during twenty-four hours
probably amounts to at least 12 to 15 oz. Occasionally the drop-
ping stops for two or three days, and then he gets a pain in the
back moving up into his head. When the flow of fluid is well re-
established the pain quite disappears, "especially," the patient
observed himself, " if I walk about until a good lot of water has
come away."
Dr. MacMunn gave the following report of an examination of the
fluid : " Reaction alkaline ; sp. gr. 1008 ; faint band of sero-lutein
in both chemical and micro-spectroscope, but much more indistinct
than in the former specimen ; the violet very distinct, but blue also
transmitted. Heat alone caused hardly any precipitate, and boiling
with a few drops of acetic acid gave only a faint turbidity. Nitric
acid in the cold produced some cloudiness soluble in excess of acid.
Chlorides were present in abundance; sulphates only in faint
traces. No red coloration with ferric chloride. Boiled with
cupric sulphate and caustic potash solution a violet reaction was
produced, and a heavy brown-red precipitate formed after boiling
and standing. (The violet reaction denoted a proteid only.) The
liquid was principally noticeable for the small amount of albumen
it contained."
In commenting on the above cases Mr. Priestley Smith says that,
" in view of the fact that ai-rest of the dropping was associated in
both cases and on many occasions with symptoms strongly sugges-
tive of cerebral compression, it is difficult at first sight to lay aside
the hypothesis of an escape of cerebro-spinal fluid ; yet this hypo-
thesis appears to be hardly tenable, for in all four of the recorded
cases (i.e. his own two, Mr. Nettleship's, and Sir James Paget's)
sugar was absent from the fluid."
He calls attention to the fact that polypoid growths were present
in two out of these four cases, and suggests that some such forma-
tion in one or other of the cavities connected with the nose may
have been in all the cases the origin of the disorder, though why a
discharge of fluid should accompany the growth of a polypus in
some cases, and be absent in all others, remains unexplained. He
points out that in both his cases severe brain symptoms with
eventual atrophy of the optic nerves, preceded the onset of the
62
THE CEREBKO-SPINAL FLUID.
dropping, and suggests that these may have been set up by en-
croachment of a morbid growth upon the upper wall of its con-
taining cavity, e. g. the sphenoid or ethmoid cells — destruction of
the bone and inflammation of the meninges. Such a condition, by
obstructing the downward flow of the fluid through the nostril,
might lead to pressure on the brain.
In tlie first of these two cases (XVII) the physical
characters of the fluid, its reaction and specific gravity,
are in favour of its being cerebro-spinal ; but the analysis
is in itself contradictory, and therefore inconclusive. It
certainly is not more suggestive of any other physiologi-
cal fluid. The clinical description, which need not here
be emphasised, is sufficient for diagnosis.
In the second of Priestley Smith's two cases (XVIII)
the analysis is quite conclusive of cerebro-spinal fluid.
The reaction, low specific gravity, scantiness of albumin
and mucin, and presence of a reducing body, are all
characteristic. The clinical description is therefore all
the more valuable.
I am indebted to Dr. Foxcroft, of Birmingham, for
kindly obtaining the subsequent history of this case. The
patient died in May, 1891, nine years after Mr. Priestley
Smith's observations were made. According to the account
of the friends the running from the nose continued at
times up to the patient's death, and he remained quite
intelligent and had no fits nor loss of consciousness. He
gradually became thinner, and died of " wasting disease."
"With reference to these two cases Mr. Priestley Smith
has kindly written to me as follows : — " Although I came
to a different conclusion at the time, I have no doubt
whatever that the cases which I published in the ' Oph-
thalmic Review ' were examples of escape of cerebro-
spinal fluid."
Case XIX. — Emeys- Jones. " Atrophy of the Optic Nerves
associated with Dropping of Fluid from the Nostril."
' The Ophthalmic Review,' vol. vii, 1888, p. 97. A
CASE BY EMEYS-JONES.
63
paper read at the meeting of the British Medical
Association in Dublin^ August, 1887.
A man aged 65, an engineer, consulted tlie author on January
21st, 1887. For twelve years he bad suffered from what he called
chronic influenza. He had not suffered from headaches for twenty
years. The discharge had not heen quite so had for the last three
years, and he thinks that when it diminished in amount his vision
began to fail. The sight of the left eye began to fail markedly,
that of the right eye slightly, about two years ago. No history of
heredity.
Sense of taste is normal. Sense of smell is not very acute. The
soft palate and the nasal mucous membrane are normal, and there
are apparently no polypoid growths. There is no thyroid enlarge-
ment, and no proptosis. He has more discharge from the left than
the right. He loses at least half an ounce of fluid in an hour.
Indoors he feels much less annoyance, and at night notices no dis-
charge.
Right eye : H. being corrected, V. = f ; colour perception normal;
field much contracted all round ; optic disc pale and atrophic.
Left eye : V. = fingers to outer side ; field much contracted all
round ; optic disc shows well-marked atrophy.
Dr. MacMunn reported on the fluid as follows : — " The fluid
closely resembles in its character that sent me by Mr. Priestley
Smith in 1883. Reaction alkaline ; sp. gr. 1'035. It failed to
reduce Fehling's solution, although when boiled with this the
solution became violet, owing to the presence of proteid; with
heat alone it became cloudy, and when acetic acid was added after
boiling the precipitate became flocculent. It was slightly pre-
cipitated by ether and by absolute alcohol ; it contained chlorides
in abundance, and traces of sulphates. It showed the band of
sero-lutein with the spectroscope.
The specific gravity and presence of some albumin and
mucin in this case point to the admixture of other secretions
with the cerebro-spinal fluid. But the chemical analysis is
inconclusive, and does not point more strongly to any other
fluid. Although cerebral symptoms were absent, I think
there are other points which justify the inclusion of the
case in the list.
Case XX. — John Beeg (Stockholm). ''^Beitrag zur
Kenntniss der Krankheiten der Nebenhohlen der
64
THE CEREBEO-SPINAL FLUID.
Nase und zur Lehre vom Ausfliessen der Cerebrospinal-
fiiissigkeit dui'ch die Nase." ' Nordisk Med. Arch./
xxij No. 3. (From abstract in ' Internat. Centralb.
fiir Laryngologie/ 1891, vol. vii, p. 358, and ' London
Medical Recorder/ 1889, vol. ii, p. 504-.)
1. Case of osteoma in the frontal sinus ; operation ; cure.
A man of 37, taken into tlie hospital on May 27th, 1887. Seven
years ago and in the last year he was obliged to keep his bed on
account of headaches ; he was afterwards in good health, until in
August his headaches commenced again, and at the same time a
large quantity of clear fluid came out of his right nostril; after
this he felt his head relieved. Later on exacerbations and remis-
sions in these symptoms took place. Three times he had attacks
of giddiness, and several times passing into paretic manifestations
on the right side.
. Present condition, — Sti'ongly built man ; pulse 60 ; temperature
normal. The memory has become bad, intelligence diminished.
He complained of constant headache, particularly over the left eye.
The left eye is pressed outwards and downwards, vision normal.
By palpation a hard tumour the size of a bean was found imme-
diately behind the orbital border in the left orbit. In the middle of
the forehead was a bony excrescence the size of a shilling. May 31st,
operation. The enlarged sinus frontalis was opened, and the cavity
was mostly filled out with a large bony tumour. After this was
removed it was seen that the cavity was besides this filled with
bony tumours varying in size from a hazel to a walnut. The
tumours are joined together by small bony bridges; they are easily
removed without its being possible to say from which point of the
sinus wall they came from. The remaining space in the cavity was
filled with a clear fluid.
Behind and above the wall of the cavity was, to a great extent,
formed by the distinctly pulsating dura mater. The cavity reached
backwards about as far as the orbit, so that the whole left frontal
lobe was certainly very considerably compromised. July 5th. — The
wound is healed ; rarely any headache ; patient is discharged. The
tumour consisted of a peripheral thin, ivoi-y bone layer, and rich
diploetic tissue.
Case XXI. — Lichtwitz. ' Archives cliniques de Bordeaux,'
No. 12, decembre, 1892.
The case is epitomised in the following words : — " Nasal hydror-
rhoea accompanied with multiple nervous phenomena, of twenty.
CASE BY LICHTWITZ.
65
nine years' duration. Considerable improvement after puncture of
the right frontal sinus, followed one year later by complete cure
after the spontaneous elimination of very abundant gelatinous
matter from the nasal cavities." The patient, who was a woman
of fifty-one years of age, related that at the age of eighteen she
suddenly expelled from the back of her throat an irregular, yellowish,
porous body, coming probably from the nose. She could give no
further details. At the age of twenty-two she had jaundice and
swelling of the face. It lasted a month, and since then {i. e. for
twenty-nine years) she had never been well ; constant colds in the
head, constant sensation of heavy weight above the nose, which,
however, was not obstructed. Her " colds in the head " came on
without any apparent cause every week or fortnight, with a watery
flow chiefly from the right nostril, and accompanied with sneezing,
photophobia, and abundant lachrymation. The nasal flow was so
px'ofuse that it soaked her clothes and her work. "When she settled
to do some work veritable little streams formed on the wooden
floor around her chair, and at night the pillows and sheets were
inundated. The liquid was clear as water, and did not stifi'en linen.
On holding the head backwards the flow took place into the back of
the throat. These attacks, which generally lasted uninterruptedly
for three days and nights, were accompanied with constant somno-
lence, complete loss of appetite, and photophobia. There was no
headache, but the attack was ushered in with shivering and general
malaise; on going to bed she perspired. On the fourth day this
flow gave place to a thicker secretion, which continued for twenty-
four hours, and then the secretion ceased until a fresh attack a few
days later. In the intervals the general malaise still continued,
although mitigated, and the patient was often obliged to keep her
room.
Since the age of forty-four (i. e. for the last seven years) the
attacks of watery flow only recurred every three weeks or every
month ; but during this period she had become subject to whitish,
gelatinous, slimy matter constantly falling into the back of her nose,
especially if she bent the head backwards. This change in the
nasal condition was accompanied by a long train of symptoms which
are too extensive to record here; amongst them were slight failure
of memory, occasional loss of consciousness, great in-itation of the
skin. Possibly many of her symptoms were neurasthenic, as
Lichtwitz suggests. But in addition she had for these seven years
also commenced to suflfer from severe symptoms in her head and
loss of vision. These pains started from the root of the nose and
radiated over tlie forehead, to finish at a fixed point in the right
parietal region. The pains were always aroused on raising herself
from a hoiizontal or a sitting position, and were very severe for
E
66
THE CEREBKO-SriNAL FLUID.
from one to three minutes. On re-seating herself the pains ceased
at once, and a few minutes later she could get up without pain. If
she remained seated for some time, however, the pains came on
when she again stood up. If she attempted to walk at this moment
she saw things obliquely, being only able to see the half of an
object situated above and to the left. This kind of hemiopsia pei*-
sists regularly from twenty to twenty-five minutes, and disappears
suddenly. The ophthalmological examination gave the following
report : — R, V. = j^, Hm. -f 150 ; fundus normal. L. V. =
Hm. + 1, Ast. 120° + 1 ; fundus normal. Slight trouble in the
crystalline lens on both sides. Considerable asthenopia, preventing
any continuous work. Visual field normal. Chromatopsia normal.
The urine was normal.
On Mai'ch 2nd, I89I, examination showed that the nasal fossae and
the naso-pharynx were perfectly normal, except for a slight paleness
of the mucous membrane. There were neither polypi, hypertrophies,
nor a trace of pus. The sensitiveness of the mucous membrane
appeared normal. The sense of smell was perfect, and hearing was
intact. The right frontal sinus was then punctured from the nose
after Schaeflfer's method ('Deut. med. Woch.,' October 9th, 1890,
p. 905). No pus escaped, but a considerable quantity of blood. Her
general symptoms were considerably relieved, and this improvement
was further accentuated by two similar tappings (the third in April,
1891). She ceased to have the attacks of watery flow from the nose,
while there was much less glairy mucus falling into the back of her
throat. In October and November, however, her former pains
returned, and she recommenced the expectoration of abundant
glairy mucus from her naso-pharynx. On November 29th this was
replaced by a profuse watery flow from the right nostril. There
was no headache and no lachrymation. This flow ceased next day,
and there was a calm until January 10th, 1892, when there was a
flow from the left nostril, — a side from which the flow had rarely
taken place alone. After another interval of comfort and relief, she
was seized, on March 20th, with sneezing and a watery flow from
both nostrils. High fever developed, and she had to go to bed,
where she remained for eleven days, expectorating from the naso-
pharynx and from the nostrils, especially the right, a large quantity
of yellowish gelatinous matter, in such quantities that fifteen
napkins were required in one day. At the end of this period the
yellowish secretion ceased suddenly, and from that date all her
symptoms, which had recurred from time to time after the puncture
of the frontal sinus, although in a much less degree, ceased com-
pletely.
On October 25th, 1892, she was still free from headache, from
attacks of watery flow, and from the falling of thick matter into the
OTHER POSSIBLE CASES.
67
naso-pliarynx. In reply to an inquiry from me, Dr. Lichtwitz
kindly wrote on March 12th, 1897, that this patient was alive and in
good health. She had not had any return of the attacks of
hydrorrhcea.
(N.B. — No watery fluid escaped when the frontal sinus was punc-
tured. The gelatinous material was expelled one year after the
puncture.— StC. T.)
The author favours the view that the liquid was not cerebro-spinal,
but had a nasal origin, for the following reasons : — Every attack
was accompanied with other symptoms, such as are often found
in the most diverse nasal affections, e.g. sneezing and lachryma-
tion. Moreover, on the fourth day of the attack, the watery liquid
was regularly I'eplaced by a mucous liquid, for which one could
invoke no other source of origin than the nose. The attacks resem-
bled those of hay fever, and only differed by their appearing at any
season and without external cause.
The liquid was not examined chemically or microscopically, but
he ventures to think that examination would have given results
similar to those obtained in cases of hydrorrhcea. He adopts
Bosworth's opinion that the secretion was due to a vaso-motor
paresis, the reflex cause in this case being situated in the right
frontal sinus. The mucous secretion, in his opinion, was due to a
chi'onic catarrh of the I'ight frontal sinus, the catarrh itself being
probably occasioned by the development of a cystic tumour in this
cavity, and preceding the onset of the hydrorrhcea.
Other Possible Cases.
The following observations which I have come across
are so suggestive of an intra-cranial origin of the nasal
discharge^ that I think it might be instructive to give ab-
stracts of them. Their descriptions are not complete
enough to justify their inclusion in either of the two
groups in which I have arranged the preceding twenty-one
cases, but in some points they help to make up the clinical
picture of the affection.
Thomas Willis. ' Opera Omnia : Cerebri Anatome/
cap. xii, Amstelasdami, clxxxii.
" Novi Foeminam illustrem, cephalea immani, nee non vex'tigine et
cerebris spirituum animalium deliquiis infestari solitam; quae cum,
68
THE CEREBRO-SPINAL FLUID.
a gravi paroxysmo, melius habere ccepisset, primo in Cevibri fastigio
motum formicantem, velut aquas irrepentis, sentiebat : dein motu
isto paulatim ante et deorsum progrediente, denium aquae limpidse
plures guttse e naribus extillabant: hoc symptoma illi passim
obtingere solebat, ut mimime dubitaret segrotans, quin lympha ista
ab ipso Cerebro extillaverit."
(I knew a distinguished lady who suffered from violent headaches,
occasionally accompanied by vertigo and loss of the animal spirits.
When recovering from a severe attack she felt as the earliest sign
a creeping movement in the brain, as of the rushing of water.
Then this feeling spread from the back to the front of the head, and
finally several drops of limpid water escaped from her nostrils. As
she frequently suffered from these symptoms the patient had little
doubt that this lymph was really distilled from her brain.)
MoRGAQNi. ' De Sedibus et Causis Morborum/ liber i,
ep. XV, art. 21.
In June, 1745, Morgagni was consulted by a Venetian lady who
for several months had been much inconvenienced by a discharge
from the left nostril. At first it was a coryza with much acrid
discharge, but afterwards the secretion was as clear as pure spring
water, and came drop by drop. As much as half an ounce an hour
escaped. When lying down it flowed into the throat in much less
quantity, so far as one could judge. The patient became thinner,
and consulted the most celebrated doctors without relief. Morgagni
tried a derivative medication. Afterwards he heard that the drop-
ping lasted many months, and then slowly declined and disappeared
within a year.
NOTHNAGEL. " Tumour of the Corpora Quadrigemina ;
Hydrocephalus ; Escape of Cerebro-spinal Fluid
through the Nose,'' 'Wiener med. Blatter/ Nos. 6,
7, aud 8, 1888 (ref. in ' Centralb. f. Larvno-oloe-ie '
Bd. V, 1889). ^ o s ,
In a patient aged 17, who had been nearly three years under
treatment for hydrocephalus acquisitus, there occurred in the last
few weeks before death a plentiful flow of liquid from the rio-ht
nostril, and in a slight degree from the right eye. The chemfcal
examination of the fluid showed that it had to do with cerebral
fluid, of which altogether more than two litres escaped. This flow
OTHER POSSIBLE CASES.
69
often intermitted, and 'on the last occasion of its intermission sucli
an increase of diffuse brain symptoms took place that it led to rise
of temperature and death. The sense of smell had diminished for
years, and in the latter month disappeared altogether. The rhino-
scopic examination and the post-mortem showed that the nose, the
lamina cribrosa, the dura, the brain, and the walls of the enormously
distended lateral ventricles were undamaged; on the other hand, the
fourth ventricle was found to be shut off by the tumour from the
aqueductus Sylvii. The flow could not, therefore, have originated in
the ventricles, but in the subarachnoid space. The liquid must
have escaped either through the lymph channels themselves, or
along the perineural sheaths of the olfactory nerves. This last
possibility is all the more worthy of consideration as the olfactory
nerve itself was atrophied from pressure. The intermittence and
the one-sidedness of the flow is not explained. The flow from the
eye is explicable either by the supposition that the fluid from the
nose penetrated along the tear duct into the conjunctival sac,
or through a communication between the arachnoid space and
the eye.
Geoh. 'Wiener med. Blatter/ No. 9, 1888. Eef. in
' Centralb. fiir Laryngologie/ v, January, 1889.
Groh mentions the case of a boy of 14 years who was imbecile,
and suffered from well-marked hydrocephalus. Whenever he lay
on the right side he had a flow of a clear serous fluid out of the
right nostril. Groh can give no further particulars, as it is many
years since the patient was under his observation, and since that
time he has not been seen.
Edward Meyer. The ' Ophthalmic Eeview/ vol. vii,
1888, p. 99.
At the meeting of the British Medical Association in 1887, and in
the debate on Mr. Emrys-Jones' paper. Dr. Edward Meyer men-
tioned a case which he had seen with von Graefe, in which there
was neuro-retinitis with nasal discharge and headache. Also a
case recently met with in his own practice, in which there was a nasal
discharge for a time, and when the discharge stopped cerebral
symptoms were developed ; there was progressive atrophy of the
optic nerves without neuritis ; vision was still good enough for the
rough work of a porter.
70
THE CEKEBRO-SPINAL FLUID.
Berg. Case 2.—'' Hydrops of the Sphenoidal Sinus ;
Trephining the Sphenoid Cavity ; Cure/' ' Centralb.
f. Laryngologie/ 1891, vii, p. 358 (same references
as for Case XVIII).
Woman of 25. lu spring of 1876 her sight began to get weak ;
patient on that account was treated by Dr. A. Berg from 1877 to
1883. In 1885 headaches and exophthalmos showed themselves, and
at intervals an abundant flow of clear yellowish, and at the com-
mencement slightly blood-stained fluid came from the nose. The
pain diminished as long as the discharge lasted. A painful sen-
sation of weight in the head set in. The author saw the invalid for
the first time in May, 1886. Considerable exophthalmos on both
sides, the movements of the eyes free, no tumours in the orbits to
be felt. Only perception of light is retained. Optic nerve atrophy,
no deformity of the nose. No other cerebral symptoms. The roof
of the naso-pharynx appeared slightly depressed. In consequence
of the constant headaches the patient's life is unbearable ; she is
ready to try everything to find relief. On June 1st, 1886, the
enucleation of the right eye was first undertaken ; the lamina papy-
racea was laid open, and at the back a centimetre of this bone was
removed with the chisel. In this way the posterior ethmoidal cells
were opened, and while the operator was driving backwards through
the cells by means of light strokes with the hammer and chisel he
opened the anterior wall of the sphenoidal sinus. This was followed
by a flow of clear fluid which filled the whole orbit. The depth of
the operation cavity was measured with a probe, and showed the
distance of the sphenoidal sinus from the orbit in the skeleton. The
cavity was drained with a drainage-tube. It healed well in six
months, the patient's head was free. The cavity remained long
draining; the soft rubber tube was changed in May, 1887, for a
silver tube. On October 17th, 1887, it was necessary again to widen
the fistula with spoon and chisel ; one could then introduce the
finger into the sphenoidal cavity and so be convinced that it was free.
Since then the patient has felt well. In September, 1888, another
clearing out of granulations with the spoon was undertaken. In
the left eye there is still only perception of light. The headache
disappeared immediately after the operation, and the patient's
general condition improved.
OTHER POSSIBLE CASES.
71
Flatau. Berliner Larjmgologisclie Gesellscliaft, April
17tli, 1896, ' Centralb. £. Laryngologie/ Bd. xii,
1896, S. 658.
Flatau showed a patient with adenoid vegetations and a chronic
hydrorrhcea which had lasted six years, and attributed by the patient
to a galvano-cauterisation of the nasal mucous membrane. The
discharge from the nose was so plentiful that it sometimes amounted
to half a litre.
'Twentieth Centuey Peactice/ vol. vi, 1806, p. 43.
In his notice of rhinorrhcea Prosser James describes the follow-
ing case : — " In November, 1878, Mr. P — came to me with a request
from his attendant that I would take him in hand, and do what was
possible to relieve his sad state. He v,'as evidently of a highly neu-
rotic disposition, and said he was in despair and had contemplated
suicide. He had for months been troubled with a constant discharge
day and night from both nostrils, in front and into the throat. He
estimated the amount at two pints in the twenty-four hours, but so
large a proportion flowed into the fauces that it Avas impossible to be
accurate. At night it saturated the pillow. He could not lie on his
back, as it produced spasmodic cough. The membrane looked rather
pale and sodden, very slightly swollen. The fluid could be seen
trickling into the pharynx. Nothing further was discovered by
careful and I'epeated examinations. The discharge was quite bland
and unirritating, never once excoriating the lip. Even the pharynx
was not congested. The fluid had a specific gravity of I"010 to
1"015, and contained a little albumin and mucin with traces of
sodium chloride and phosphate. This gentleman came to me at
intervals until the following February, after which he ceased to
attend. During these months there were fluctuations in the
amount of discharge, so that at times he was much encouraged and
at others depressed. Some months afterwards he called to explain
his absence, which was caused by an attack of typhoid fever from
which he recovered very slowly, but when convalescence set in he
found to his great satisfaction that his nasal trouble had completely
disappeared."
Tlie analysis of the fluid in the above case is too meagre
to settle the diagnosis. It does not point distinctly to
cerebro- spinal fluid, nor, on the other hand, does it
72
THE CEREBRO-SPINAL FLUID.
negative such a supposition. As to the clinical account,
the fact that the flow was from both nostrils is not
decidedly in favour of the view that the discharge came
from the cranial cavity; but it is well to remember that
in Case VI it is noted that the liquid came from both
sides, although the positive evidence of the post-mortem
showed that a communication existed only on one side.
On the other hand, the fact that the flow was also con-
tinuous by night is suspicious, and so is the presumably
negative condition of the nasal fossae.
I need hardly add that in my search for the cases
which have been here considered I have read through a
very large number of records of instances of nasal hydror-
rhoea — which after all is only a symptom, and not a
disease, — where the fluid was undoubtedly secreted by
the mucous surfaces of the nose or its accessory cavities.
The main points of these twelve probable cases of
cerebro-spinal rhinorrhoea may be tabulated as follows
{vide Table B).
TABLE B.
74
THE CEREBKO-SPINAL PLDIl).
Table B. — Cases in tchich the Fluid discharged from the No.
No.
Author,
reference.
Sex
and
age.
Soration.
Cerebral symptoms.
Eye symptoms.
General.
X
King,
Lond. Med.
and Surg.
Journ., iv,
1834, p. 823
F.,
52
3 months
Patient stout
puffy eyelids;
disposition to
anasarca
XI
Elliotson,
Med. Times
and Gaz.,
1857, New
Series, vol.
XV, p. 290
F.,
40
23 months
First attack pre-
ceded by severe
pain in head, which
ceased when flow
became established
All lier secretio
and functions vn
undisturbed
XII
Paget,
Trans. Clin.
Soc, xii,
10/0, p. 40
F.,
49
18 months
Very severe head-
ache 4 months
previous to onset
of flow. Death
from meningitis
—
XIII
Fischer,
Deut. Zeits.
f. Chir.,
1880, Bd.
xii, s. 369
M.,
42
Several
hours
Suffered from
headaches, which
were always
relieved by flow
Otherwise per
fectly healthj
XIV
Speirs,
Lancet,
1881,
March 5 th,
p. 369
M.,
55
9 months
TABLE B.
75
? most probably Cerebrospinal Fluid {in chronological order).
fostril affected,
cessory cavities.
History.
Progress and
results.
Quantity and character
of fluid.
Diagnosis.
Left
Continuous clay
and night ; had to
wear a sponge. No
treatment, local or
general, of any
avail
A quart in 24
hours; clear
limpid fluid
t ; no sneezing;
no ansemia
Similar attack
14 years pre-
viously, lasting
18 months
Continuous day
and night. Result:
complete disap-
pearance, and no
return after
14 years
3 quarts in a day;
colourless, no
odour; handker-
chiefs dried soft.
T^ids Analysis
—
Left
History
insignificant
Continuous day and
night; quantity
generally uniform,
but always in-
creased by mental
distress, by exer-
tion, or by strain-
ing; ceasedoncefor
14 days, and once
in the night; other-
wise continuous.
Result : death
4 ounces were
collected in an
afternoon and
evening, like pure
water, or the fluid
of the pia mater,
or that of an
acephalocyst.
Vide Analysis
In life, derived
from fi'ontal or
ethmoidal sinus ;
after autopsy,
brought about
by polypi in left
antrum of
Highmore.
Left
This phenomenon
had occurred three
times
Turbid watery
fluid, 200 grammes
in course of several
hours. Vide
Analysis
Hydrops of
frontal sinus,
which emptied
itself periodi-
cally.
At first
attributed to
stooping
position as a
tailor
Continuous day
and night ; ceased
after introducing
goose grease into
nose
An ounce in
quarter of an hour;
at times copious ;
handkerchiefs
dried soft
Dropsy of
maxillary
antrum.
76
THE CEREBRO-SPINAL FLUID.
No.
Autlior,
reference.
Sex
and
age.
Duration.
Cerebral symptoms.
Eye symptoms.
General.
XV
Baxter,
Brain, iv.
Tan
p. 525
F.,
35
3i years
Preceded by head-
aches, and severe
headaches con-
tinued with
establishment of
flow ; vomiting,
convulsions, coma
Subsequent to
onset of di ipping
from nose came
double optic
neuritis, hemi-
opia, and later,
blindness; most
marked in right
Hysterical
XVI
Nettleship,
Ophthal.
Review, ii,
P.,
23
1, and
possibly
3 years
18 months pre-
viously "lost her
senses, forgot her
words, and was up-
set in her brain,"
with headache and
prostration; when
sight failed head-
aches ceased
eye
Sight failed
12 months
before running
from nose
appeared ;
post-papillitic
atrophy; left
eye worse
Palpitation anc
hysterical attack
some loss of tas
and smell; weal
ness of left sidt
of body
XVII
Priestley
Smith,
Ophthal.
Review,
ii, 1883,
V' ^
M.,
28
2 to 3 years
Four years
previously severe
headaches and
vouiiting.Once flow
of fluid ceased, and
\xQ hud drowsiriGss.
A second time flow
ceased, and he
became convulsed,
unconscious, and
died
After headaches
began, failure of
sight set in ;
double optic
atrophy (worse
leit), ana buna-
ness in 4 months.
Horizontal
nystagmus
XVIII
XIX
Priestley
Smith,
Ophthal.
Review,
ii, 1883,
p. 4
Emrys-
Jones,
Ophthal.
Iteview,
vii, 1888,
p. 97
M.,
22
M.,
65
4 years
12 years ;
eye
symptoms
for 3 years
At age of 17, after
overwork and head-
ache, sudden pain
in head and uncon-
sciousness; pain,
vomiting, delirium,
and tits during
4 months ; for 14
months paraplegia,
involuntary
micturition and
defsecation
No headache for
20 years
During uncon-
sciousness
became totally
blind; double
optic atrophy
Discharge
diminishing for
2 years, during
which time his
sight had been
failing; atrophy
of optic discs,
more marked on
left side
Dropping com-
menced 2^ year
after the
beginning of th
attack
Taste normal ;
smell not very
acute
TABLE B. 77
ostril affected,
sessory cavities.
History.
Progress and
results.
Quantity and character
of fluid.
Diagnosis.
Right
Came on after
worry ;
symptoms
overlaid with
hysterical
manifestations
Steadily grew
worse. Died
comatose. Post-
mortem negative
Clear watery fluid ;
only occasionallj'
offensive to
patient, not to
others; and
sometimes blood-
tinged
Left
Healthy
appearance ;
no vomiting
Fluid is said to
have given no
trouble when she
was in bed ; no
treatment
efficacious ; sight
did not alter;
flow ceased
Profuse running;
fluid colourless,
slightly ropy; no
sugar, but albumin
and mucin.
Vide Analysis
From the
analysis it is
concluded that
the fluid was
derived from the
nasal cavities,
and was not
meningeal.
jft, but after
sation of one
i, through the
ight nostril
Four months after
it started, flow
ceased for 7 days.
Ceased again before
death. No post-
mortem
5 drops per
minute ; 18 ounces
in 24 hours.
Colourless, clear,
1007; no sugar
Difficult to lay
aside the
hypothesis of
cerebro-spinal
fluid, but not
tenable in view
of analysis.
fht, and when
his became
eluded with
'pus, from the
left
Some recovery
in legs.
Intelligence
quite regained
Occasionally
dropping stops for
2 or 3 days, when
he gets a pain in
his head; when
flow is re-estab-
lished the pain
quite disappears
12 to 15 ounces
in 24 hours ; sp.
gr. 1008; alkaline;
no sugar; small
amount of albu-
men
Same as in
Case XV.
Dre from left
n from right
Discharge is less
indoors, and not
noticed at night
Half an ounce an
hour; alkaline;
1035 ; no sugar
78
THE CEREBRO-SPINAL FLUID.
No.
Author,
reference.
Age
and
sex.
Duration.
Cerebral symptoms.
Eye symptoms.
General.
XX
Berg,
Centralb. f.
Laryngol.,
vii, 1891, p.
358; Lond.
Med. Re-
cord, 1889,
ii, p. 504
M.,
37
9 months
Seven years and
one year previously
severe headaches ;
giddiness; right-
sided paresis ;
constant headache
over left eye
Left proptosis
Memory bad;
intelligence
diminished
XXI
Lichtwitz,
Archiv.
Clin, de
Bordeaux,
No. 12,
Dec, 1892
r.,
51
29 years
Pains in head ;
attacks ushered
in with somno-
lence, loss of
appetite, and
photophobia ;
vague pains in
all the body,
especially in the
nails
Asthenopia ;
fundi normal
Smell and hearin
intact; urine
normal
TABLE B. 79
stril affected,
essory cavities.
History,
Progress aud
results.
Quantity and character
of fluid.
Diagnosis.
Right
Osteoma of left
frontal sinus
removed; recovery
from operation ;
headache rare ;
presumably
hydrorrhoea ceased
Clear fluid
Cerebro-spinal
rhinorrhoea
Right
—
Flow continuous
day and night;
improvement after
puncture of right
frontal sinus,
followed in one
year by sponta-
neous elimination
of abundant gela-
tinous matter and
complete cessation
of hydrorrhoea
Clear as water,
and did not stiffen
linen; so profuse
as to soak clothes
Vaso-motor
rhinitis excited
by chronic
catarrh of right
frontal sinus.
80
THE CEREBRO-SPINAL FLUID.
Summary op Twelve Pkobablb Cases op Cerebeo-spinal
Rhinorrhcea.
From these twelve cases the following points may be
summarised, and it will be seen that when compared with
Table A our conclusions have to be both amplified and
modified.
Females 6, males 6 ; this confirms the previous con-
clusion that both sexes are equally affected.
Age from 22 upwards to 51, 55, and 65 ; this shows
that it may appear at any period during adolescence.
Side of nose affected, five times left ; once it was more
from left than from right ; twice it alternated ; three
times right ; once not mentioned. This confirms the con-
clusion of Table A that the left side is more frequently
affected.
Cerebral symptoms in nine cases, eye symptoms in five
cases.
Intermission in the fiow in . .6 cases.
Flow continuous day and night in . 5 „
Not noticed at night in . . 2 ,,
Not mentioned in . . 5 „
Complete disappearance of the drop-
ping without bad symptoms in . 4
Death with cerebral symptoms in . 3 „
Post-mortem in . . . 2 ,,
The first autopsy (Case XII) showed diffuse meningitis
and polypi in the maxillary antrum of the affected side.
In the second case (Case XV) the result of the examination
was entirely negative. Nothing abnormal was discovered
in the interior of the skull, the brain, or its membranes.
The cavities of the sphenoid and ethmoid presented no
evidence of disease.
NASAL HYDRORRHCEA.
81
Diagnosis prom Nasal Hydrorrhcea.
Before commencing to comment on these cases I think
it advisable to first of all clear up two different explana-
tions which may be offered in regard to them. The first
is that the flow was from the nasal mucous membrane
itself. This, indeed, is the theory of Bosworth in refer-
ence to several in my second group. Now excessive
watery discharge from the nasal mucosa is of course a
physiological possibility. We know that the turbinals
are freely supplied with blood-vessels, elastic tissue,
unstriped muscular tissue, and large blood-spaces, — in
fact, erectile tissue capable of speedy engorgement, and
of so much "watery secretion that even in the condition
of health it yields sufficient to completely saturate the
inspired air. The amount of water which is thus being
constantly secreted by the nose must vary greatly ; for not
only does it depend on the degree of moisture in the
inspired air, but also on diet, exercise, &c. It may be
roughly estimated from 350 to 1400 grammes per diem.^
It is not surprising that under diseased conditions this
special secretory arrangement should yield a much larger
supply of liquid. The following is a very marked case of
hyper-secretion from the nasal mucosa.
Illustrative Case of True Nasal Hydrorrhoea.
B. PouLssoN. A Case of Hydrorrhoea Nasalis,^' ' Med.
Soc. Christiania Reports,^ 1895. From abstract in
'Journal of Laryngology,' vol. xi, 1896, p. 114.
^ Aschenbrandt, ' Die Bedeutung der Nase fiir die Atmung,' Wiirzburg,
1886; Kayser, "Die Bedeutung der Nase fiir die Respiration," 'Pfliiger's
Archiv,' Bd. xli, 1887; Bloch, "Zur Physiologic der Nasenatmung," ' Zeit-
schrift f. Ohrenheilk.,' Bd. xviii, 1888; MacDonald, 'Respiratory Functions
of the Nose,' London, 1889; Schiitter, ' Annales des mal de I'Oreille,' April,
1893.
r
82
THE CEREBRO-SPINAL FLUID.
(The case is also published in the ' Norsk. Mag. f.
Laegevidenskaben/ 1895, 441.)
A man aged 30, otherwise healthy, commenced in his thirteenth
year to suffer three and four times yearly from attacks of excessive
nasal secretion, lasting three and four days, The attacks by degrees
became more and more frequent, the secretion more abundant and
watery, while the duration of each attack was shorter. The attacks
now generally appear every second week, and last one or two days ;
they commence generally in the morning with a sensation of irrita-
tion in the nose and pressure over the forehead, and when the patient
gets out of bed the secretion becomes so abundant that it is impos-
sible for the patient to do anything but to sit quietly and let the fluid
flow into a basin ; when obliged to move about he must hold a hand-
kerchief constantly to his nose. This flow continues until about two
o'clock at night, when he generally falls asleep, the discharge then
leaving off until the following morning, when he wakes up to suffer
again like the previous day, until the flow suddenly stops during the
afternoon. The quantity of fluid discharged during an attack is
estimated to be about one litre. The examination of the fluid gave
the following result : — Watery, white opalescent fluid of slight alka-
line reaction ; specific gravity, 1"006 — 1"007 ; 0'02 per cent, of
albumen, 0'93 per cent, of salts, principally chloride of sodium and
iron, and small quantities of a fatty substance ; microscopically
white corpuscles. The examination of the nasal cavities did not
reveal any abnormality. The patient had tried various treatments
■without any result. Atropine in a one tenth per cent, solution had
been prescribed, and the patient had derived great benefit from the
drug, ten drops of the solution being often able to check the attacks
or to lessen their intensity ; and although this medicine had been
taken for a considerable period of time, no ill effects had been ob-
served. Dr. Poulsson considered the affection to be of a purely
nervous character, but would refrain from giving any opinion as to
whether it must be considered an affection of the fifth nerve or of the
sympathetic.
This case is undoubtedly one of pui*e hydrorrhcea
nasalis ; the intermission in the attacks, the onset with
local irritation, the cessation during sleep, the bilateral
flow, and the analysis of the fluid all confirm this view.
But the case arrested my attention chiefly from the large
amount of fluid which was secreted, so I wrote to Dr.
Poulsson asking for some'further details, which he most
kindly supplied. At the date of his letter in March,
NASAL HYDKORRH(EA.
83
1897, tlie patient was still subject to these attacks. It
had been impossible to measure the amount of secretion
in an hour, but during an attack of two days it had
amounted to one litre. It flows equally from both,
nostrils. The attacks are nearly always ushered in with,
sneezing ; this sneezing ceases when the flow is fully
established. The patient is not subject to headaches, and
finds no relief from the secretion ; indeed, he always
feels unwell and tired both during and after the attack.
The attacks recur quite irregularly, the intervals varying
from a few days to a few weeks ; as a rule he has two
attacks per month. Examination of the nasal fossae and
accessory sinuses showed no pathological changes ; during
the flow the mucous membrane becomes swollen. Finally
the patient's eyesight is quite normal.
Dr. Poulsson further increased my indebtedness to
him by sending me from Christiania a bottle of the nasal
secretion, and I am thus enabled to submit and contrast
the analysis of a typical and undoubted case of real
hydi'orrhoea nasalis with that of a nasal flow of cerebro-
spinal fluid. Professor Halliburton's report is as fol-
lows :
Chemical Analysis of Secretion in Nasal Hydrorrhoea,
" King's College, Marcli 8tL, 1897.
" I have examined the Norwegian fluid, with the following results :
" In the first place, it gives a precipitate of a viscous character
with acetic acid. This indicates the presence of mucin or of a mucin-
like substance. I collected this precipitate, and boiled it with dilute
sulphuric acid for some time ; then neutralised and filtered, The
filtrate did not reduce Fehling's solution. This shows that the siib-
stance in question is not true mucin ; or if it is true mucin, the
quantity at my disposal was too small to admit of my obtaining any
reducing substance from it.
" The rest of the original fluid was diluted with about four times
its volume of absolute alcohol. The precipitate of proteid matter
that resulted from this treatment was much more abundant than in
cases of cerebro- spinal fluid. The precipitate was filtered off, and
both precipitate and filtrate examined.
84
THE CEllEBRO-SPINAL FLUID.
" (1) The precipitate. — This was dissolved in saline solution, and
was found to be composed of the mucinoid material just referred to,
together with a small amount of proteid coagulable by heat. Pro-
teoses and peptones were absent.
" (2) The filtrate was evaporated to dryness at 40° C, and the dry
residue consisted of salts, mainly sodium chloride. The residue also
contained a substance which reduced Fehling's solution. This sub-
stance gave the phenyl-hydrazine test for sugar, and also the fermen-
tation test with yeast. After the action of yeast no reducing sub-
stance was left in solution,
" The conclusion I draw from these experiments is that the fluid
is not cerebro-spinal fluid. It contains a mucinoid substance which
is absent from cerebro-spinal fluid. It contains more proteid matter
than cerebro-spinal fluid; further, the reducing substance in it is
sugai', and not the peculiar reducing material in cerebro-spinal
fluid.
"I regard the fluid as a serous exudation; such fluid usually con-
tains sugar. The mucinoid material is doubtless from the nasal
mucous membrane.
" Microscopically a few colourless corpuscles ; no booklets.
" W. D. Halliburton."
In order to still more fully contrast the chemical
characters of the fluid in cerebro-spinal rhinorrhoea with
the liquid obtained in cases of ordinary nasal hydrorrhoea
(vaso-motor rhinitis)^ I collected some of the latter from
one of my own female patients during an attack. This
was submitted to Professor Halliburton, who most kindly
sent me the following exhaustive report :
" The fluid is thick and viscid, and slightly opalescent. On micro-
scopic examination it shows the usual appearances presented by
mucus, viz. amorphous matter with mucous corpuscles.
" It gives with acetic acid and also with alcohol a stringy precipi-
tate like that given by mucin. On boiling this precipitate with
dilute sulphuric acid a reducing sugar-like material is formed ;
this also is characteristic of mucin.
" The fluid contains a small amount of proteid coagulable by heat ;
it does not reduce Fehling's solution. Proteoses and peptone are
absent. The alcoholic exti-act of the fluid contains no reducing
substance.
" Analysis gives the following results :
NASAL HYDROREHCEA.
85
"Water .... ^S'^QS 7 . iqO
Total solids .... 1-208)
Proteids (including the mucin) . 0"260
Other organic substances . . 0'163
Inorganic substances . . . 0"785
" The presence of mucin and absence of reducing substance, as
well as the percentage of proteids and solids, are quite sufiBcient to
distinguish this fluid from normal cerebro- spinal fluid. The fluid
resembles the Norwegian fluid on the whole, but is more viscid and
richer in mucin.
" W. D. Haelibtirton,
King's College, London.
" October Vlth, 1897 "
Other Points of Diagnostic Difference.
Such cases, in a milder form, are not uncommon,
and the points which distinguish them are the follow-
ing : — The flow takes place almost invariably from both
nostrils, although sometimes more from one than from
the other. It is not noticeably influenced by the position
of the head. It ceases during sleep. It is, as a rule,
preceded or accompanied by other signs of irritation of
the mucous membrane, such as sneezing, lachrymation,
photophobia. The flow is very variable, and seldom has
any regularity either in the dripping or in the intermis-
sion ; but the flow is seldom continuous for more than a
few hours or a few days at a time. One patient informs
me that she will be feeling quite well when suddenly she
is seized with sneezing, and that before she can get out
her handkerchief the fluid pours in a stream from her
nose. At other times it comes in such a steady drip
that she just places her handkerchief on her lap to catch
it. Headache is not relieved by the flow, but is as a
rule made worse. Cerebral symptoms are not marked.
Ocular symptoms in connection with it are unknown,
except for some conjunctival irritation.
86
THE CEREBRO-SPINAL FLUID.
Chemical Composition of Cerehro-s'pinal Fluid.
Finally, the chemical analysis may generally be relied
upon to settle the diagnosis in all doubtful cases. In
8 out of the 9 cases in Group " A this analysis is suffi-
ciently complete ; in the seventh case the post-mortem
showed the origin of the fluid. Of the 12 cases in
Group " B " we have an analysis of the liquid in 7
cases, and a study of the results therein given, when
compared with the standard analysis of undoubted cases
of pure nasal hydrorrhoea and of cerebro-spinal rhinor-
rhcea will suffice to show that in each of these 7 cases
the chemical reactions point towards the cerebral source
of the liquid. In the remaining cases the fluid was
reported to be clear and limpid ; and in 3 cases of
Group B, as in my own, the secretion did not stiffen
linen, but the handkerchiefs " dried soft," and could be
used again if necessary.
At the period when several of the above cases were
recorded it was taught by Hoppe-Seyler ^ that the normal
cerebro-spinal fluid had no copper-reducing substance in
it, and that this latter was not obtainable from the first
puncture of spina bifida and hydrocephalus, but only from
later punctures and from the fluid in cases of meningitis.
Hence he thought that the presence of the reducing body
was a sign of irritation and inflammation. This has all
been proved to be incorrect, but it serves to show how
inadequate the tests were at that date. The same reasons
may account for the absence of sugar in the analyses in
4 cases (viz. XII, XVI, XVII, XIX) . One of Priestley
Smithes cases (XYIII), however, did show a reducing body
with Fehling's solution.
The uncertain views still held with regard to the
chemical composition of the cerebro-spinal fluid is shown
by a recent paragraph in the ' Lancet ' (November 6th,
1897, p. 1199). It is there stated that the investigations
1 ' Physiol. Chemie/ Berlin, 1881, S. 605, 608.
CHEMICAL COMPOSITION.
87
o£ various cliemists liave been without satisfactory results,
partly, perhaps, because the fluid has been examined not
in healthy but in diseased conditions. The question at
issue is further confused in this paragraph by a clerical
error in attributing to Hammarsten ('Physiological
Chemistry') the opinion that the body which reduces
copper oxide is fermentable," a statement that is not
compatible with its being pyrocatechin. Prof. Halli-
burton found on communicating with Hammarsten that
this was a misprint for " unfermentable." In the same
paragraph the researches of Dr. B. Nawratzki, of the
Dalldorf Asylum for the Insane, are quoted. He obtained
cerebro-spinal fluid from the calf by means of lumbar
puncture, and the results of his tests are in opposition to
Hoppe-Seyler and others, for he finds that in health a
substance is present which in all its properties agrees
with grape-sugar, while pyrocatechin is entirely absent.
It is possible that the sugar found by Nawratzki was
obtained from the blood, admixture with which he admits
while making the puncture. He states that the amount
of sugar he obtained was less than that in the blood. If
the reducing substance is all sugar it should be more
abundant, the reducing substance in cerebro-spinal fluid
being considerable ; in fact, its presence is the most
striking feature about cerebro-spinal fluid. There are
other reasons, which need not be detailed here, for think-
ing that some serious errors must have crept into his
experiments. My own case has happily afforded Professor
Halliburton repeated opportunities of examining consider-
able quantities of human cerebro-spinal fluid, obtained in
an almost absolutely pure condition, and his analyses have
only confirmed one another in the results obtained. These
results will form a standard of reference for the future,
and help to reconcile the doubtful and conflicting analyses
in the past. The chemical results of analysis in several
of the cases in Group ''B " need not therefore, by them-
selves, be looked upon as decisive as to the origin of the
fluid.
88
THE CEEEBRO-SPINAL FLUID.
Diagnosis prom So-called Dropsy op the Antrum.
But if the bilateral character of the flow is the principal
point in eliminating the possibility of the secretion in
question being intra-nasal in origin, this objection does
not hold in regard to the second chief argument which
will be urged against my thesis ; I mean the suggestion
that the watery fluid is a dropsy of the antrum of
Highmore, or of the frontal sinus. This, in fact, is the
explanation which was given by Sir James Paget of the
second case in this group, and it requii'es due consider-
ation because, possibly without sufficiently careful study,
his case has been quoted by many of the observers which
have followed him, and it has evidently biassed their
diagnosis.
The following would appear at first sight to be a well-
authenticated case of one-sided nasal hydrorrhoea origi-
nating in the maxillary antrum.
A. R. Anderson (Nottingham). — "Nasal Hydrorrhoea,"
* Lancet,' 1892, vol. i, p. 474. (Also reported in the
'Brit. Med. Journ.,' February 6tli, 1892, p. 276.)
A young woman, aged 19, had for some time been troubled with
a perfectly clear, watery discbarge from the left nostril. The dis-
charge was almost continuous, but could be increased by inclination
of the head to the opposite side, and after a quantity had flowed
forth in this Avay it would for a time cease. There was no symptom
or sign of disease in either the ethmoidal, frontal, or sphenoidal
sinuses, and no tumefaction of the cheek or other sign of distension
of the antrum. Nothing could be discovered in the anterior or
posterior nares. From the symptoms it appeared evident that the
antrum furnished the discharge. The molar teeth on the affected
side were carious, and the cavity was opened by extracting the
second and peforating the bone, when a quantity of clear fluid
similar to that discharged from the nose was evacuated. The cavity
was drained into the mouth and douched daily with an astringent
wash. This did not effect a cure, so the opening in the bone was
enlarged to a 8ufl5cient extent to admit the end of the little finger.
SO-CALLED DROPSY OF THE ANTRUM.
89
when a number of minute polypi were found projecting from the
mucous lining of the antrum. The interior was scraped with
a director and swabbed out with a solution of chloride of zinc,
which effected a cure in about six weeks. When last seen some
months after, the patient was quite well, and had no recurrence of the
symptoms. Allusion was made to a case very similar to the above
in many respects which had been reported by Sir James Paget to
the Clinical Society in 1878.
It is notewortliy tliat in the above^ as in so many cases
in Groups " A " and " B/' the discharge was from the
left side. As the cavity was drained into the mouth and
yet the watery discharge from the nose did not cease^ I
think the case is quite open to the suggestion that it may
have been one of cerebro-spinal rhinorrhoea, and that the
polypoid degeneration of the lining of the antrum was a
coincidence.
A secretion so watery and abundant as it was reported
to be in most of the cases, is in all probability the
product of a vascular organ especially adapted for secret-
ing, such as the choroid plexus of the ventricles. Leber
compares the secretion to that of the ciliaiy processes of
the eye and the glomeruli of the kidney.
Seeods Accumulation in the Maxillary Sinus.
Now there is a very strong a 'priori argument against
the possibility of the mucous lining of the antrum being
able to secrete mucus or watery fluid to any great extent.
It is considerably thinner than the nasal mucosa ; the
mucous glands are much scantier, — Sappey,^ indeed, only
found some on the floor of the sinus. Zuckerkandl^ says
they are distributed on all the walls, but that they are
neither so regular nor so numerous as in the mucous
membrane of the nose. In any case there are no vas-
cular arrangements like the erectile tissue in the nose, for
' ' Traite d' Anatomic,' tome ii, 2e partie, 2e fasc, p. 744.
2 'Anatomie normale et pathologique des Fosses Nasales,' traduit en
rran9ais, 1895, tome i, p. 310.
90
THE CEREBRO-SPINAL FLUID.
the secretion of a large amount of watery fluid. In catarrh
of the maxillary sinus the mucus secreted amounts to
very little,, and is only established when hypereemia
exists for some time. "Then/' says Zuckerkandl,
" exudation chiefly takes place in the substance of the
lining membrane of the antrum. It is not only the mucosa,
but rather the deeper layers of the membrane which
serve the function of periosteum, which present this
infiltration of the structure ; the swollen membrane,
when the affection is intense, attains to ten or fifteen
times its original thickness ; it is infiltrated with serum,
oedematous, jelly-like, and its free surface is dotted with
bulgings of a clear yellowish white, filled with liquid.
The glands at the same time undergo cystic degeneration.
When the whole mucous lining presents this degeneration
the sinus appears as if affected with dropsy. As a rule
the lumen of the sinus is simply narrowed, according to
the amount of swelling of the mucosa ; it contains, along
with air, a greater or less quantity of liquid mucus. ^'
But Giraldes^ gives a very similar account of the struc-
ture of the mucous lining of the antrum. With regard
to the mucous cysts, he had found as many as twenty in
one specimen, and sometimes bigger than a pigeon's egg.
He quotes Groubaux to the effect that these tumours are
common in cows. It would be interesting to know if these
animals are subject to nasal hydrorrhcea. The walls of
these cysts are thin, and the contents vary. As a rule it
is a viscous liquid, thick, stringy, transparent, and some-
times yellowish. In other cases it is opaque and even
caseous. In larger cysts it is more liquid, yellowish white,
sometimes transparent and syrupy in consistence, or
stringy, like white of egg. But the important point of
Giraldes* observations is the statement that he is not
aware of a single autopsy where the liquid has been found
free in the sinus, and so offered any analogy to the dropsy
described by some authors. Indeed, he challenges the
production of a single post-mortem demonstrating the
1 ' Kecherches sur les Kystes muqueux du Sinus maxillaire,' Paris, I860.
SO-CALLED DROPSY OP THE ANTRUM.
91
presence in the cavity of tlie sinus of this so-called
dropsy.
Evidently the contents of these cysts bears no resem-
blance to the watery fluid which escapes from the nose ;
and any free secretion which their presence may excite in
the cavity is much too slight even to amount to a dripping
from the nares. That would presuppose that the sinus
was completely filled — the orifice being on an upper plane
— and constantly replenished.
In a discussion on this subject at the Societe de Chi-
rurgie ^ MM. Berger and Magitot said that dropsy of the
antrum was a condition they had never met with^ and one
of which they positively contested the existence. The so-
called retention cysts of this cavity should also be rele-
gated to the legends of last century, always excepting
the cysts (so-called " cysts of Giraldes ") which are deve-
loped in the mucous glands of the walls of the sinus.
In spite of the pathological objections of Giraldes,
Luschka (1855)/ Virchow (1863)/ Zuckerkandl (1882)/
Heymann (1892)/ and Dmochowski (1895)/ the current
literature of diseases of the upper air-passages continues
to have references to what are termed mucoceles of the
accessory sinuses, with suggestions of symptoms of cases
somewhat like those in my second group. Under the
heading of " Mucocele," Jonathan Wright, who has done
most valuable work in the pathology of diseases of the
nose, thus refers to the matter in a recent publication : ^
1 • Bulletin et Memoires,' tome xiv, 1888, Seances du 28 mars et du 11
avril.
2 Luschka, " Die Schleimpolypen der Oberkieferhohle," ' Virch. Arch.,'
Bd. viii, S. 419.
» Virchow, ' Die krankhaften Geschwiiltse,' Bd. i, S. 245.
Zuckerkandl (loc. cit.).
5 Heymann, " Ueber gutartige Geschwiilste der Highmorshohle," ' Virch.
Arch.,' Bd. cxxix, S. 214.
6 Dmochowski, "Beitrag zur patholog. Anatomie und Aetiologie der
enziindlichen Processe im Antrum Highmori," 'Archiv fiir Laryiigol.,'
Bd. iii, S. 284.
T • Twentieth Century Practice,' vol. vi, 1896, p. 93.
92
THE CEREBEO-SPINAL FLUID.
" Cases have been reported from time to time of serous accumu-
lations in the antrum of Highmore. Their pathology is not under-
stood. The symptoms they present are very indefinite, being chiefly
sensations of pain and heaviness in the head and the ordinary
symptoms of chronic rhinitis. There is an intermittent watery
discharge from the nose. Occasionally the watery discharge is
more or less constant. This symptom, as, indeed, also the pain,
apparently depends upon the degree of permeability of the ostium
maxillare. A satisfactory diagnosis can be made only by puncture
with the trocar and cannula. . . . These cases seem to be, at
least in this country, of very rare occurrence."
"With regard to the frontal sinus he remarks (p. 99), "Accumu-
lations of serum and of mucus in the frontal sinus have been
frequently reported. . . . There may be a continuous or an
intermittent discharge of clear fluid or of mucus from the nose, or
there may be no such discharge, but distension of the inferior walls
of the sinus."
Noltenius ^ reports thirty-seven cases in which, by
exploratory aspiration, he found serous exudation in the
maxillary sinus, the liquid being clear and slightly amber-
coloured ; in two cases it held in suspension little flakes.
The principal symptoms are supra-orbital neuralgia, nasal
obstruction without any hypertrophy to explain it, and
much more rarely attacks of nasal hydrorrhoea.
But Alexander^ points out that the exploratory puncture
of the maxillary sinus and withdrawal of serous fluid is
no diagnostic proof of a retention dropsy of the antrum,
for the serous fluid might have been contained in the
cysts or extravasated in the antral cavity after the collapse
of the cyst walls. Although he grants that serous exu-
dation in the cavity is theoretically possible, he asserts
that absolute proof of such a condition is not forthcoming.
The challenge made by Givaldes in 1860 still remains
unanswered. Alexander examined seven cases with poly-
poid degeneration of the mucous lining of the antrum.
There was some hypersecretion, but no nasal hydrorrhoea
in any of them. He found the contents of the cysts to
1 'Monatsh. f. Ohrenh./ April, 1895, p. 114; from ref. in 'Annal. des
Mai. de I'Oreille.'
2 ' Archiv f ur Laryngologie,' Bd, vi, 1897, Heft 1, S. 130.
SO-CALLED DROPSY OF THE ANTRUM.
93
be a greenish-yellow serous fluid, which, on standing,
stiffened to a gelatinous mass, and on boiling solidified
completely. The chemical analysis he made gave the
following result :
Water .... 91±
Dry residue . . . . 8"5 (7*4! being albumin).
Ash ..... 0-3.
Affections of the frontal sinus so frequently lead to
displacement of the eye that we have to seek in ophthal-
mic literature for illustrative cases affecting this sinus.
Silcock ^ explains distension of the frontal sinus as being
due to the retention of the mucous secretion of the cavity
from temporary or permanent blocking of the infundibu-
lum. He considers that empyema of the frontal sinus is
not so often met with as simple retained mucus disten-
sion. In the cases he records he found within the sinus
"thick, greenish, tenacious stuff, very like half-melted
size, or partly decolourised bird-lime ; " the mucous
membrane was hypertrophied, and in one instance he
found polypi.
But the record of the " tenacious stuff, very like half-
melted size,^^ and the description of the condition of the
mucous membrane, are very suggestive of the pathological
condition of cystic degeneration described by Griraldes
and Zuckerkandl. There is no record of rhinorrhoea in
any of Mr. Silcock's cases, although one had previously
had a discharge from his nostrils, copious in cold
weather. When examined, this was found to be muco-
pus.
Cresswell Baber and Bond^ have published cases of what
are termed " mucocele " of the frontal sinus. In both
cases the collection of clear viscid mucus which was
discovered in the cavity was attributed to the obstruction
of the fronto-nasal duct. In neither case was there any
watery discharge from the nose.
1 The ' Practitioner,' 1897, vol. i, p. 244.
2 ' Proceed. Laryngol. Soc. Lond.,' vol. iv, 1896-7.
94
THE CEREBRO-SPINAL FLUID.
Diagnosis from Water inspired and retained.
Still another possible source of origin of the watery
flow from one side of the nose has been suggested by
Lingard/ who thinks that in the following case the water
used for washing was drawn up by the patient into the
accessory siunses of the nose, from which it trickled out
when he bent his head forwards.
A gentleman aged 26 liad suffered great inconvenience for nine
months from a watery discbarge from his right nostril, which came
on at intervals during the day, also right frontal headache. "With
the exception of a fall fi'om a height of forty-five feet on his right
forehead fifteen years previously, nothing was found to account for
the symptom. The author was inclined to refer it to this cause,
and supposed that some fracture of the cribriform plate of the
ethmoid might possibly have taken place and allowed the escape of
the cerebro-spinal fluid. The patient could not suggest any other
cause for its occurrence, and had never suffered either from polypus
or syphilis. It was observed that the flow depended wholly on the
position of the head. Totally absent when on his back or in the
upi'ight position, it invariably occurred on bending forward the
head, — as, for example, in reading or writing, which was annoying, as
a few drops of straw-coloured fluid would fall on his books or papers.
It was by accident that the author found out the real cause. On
visiting his patient earlier than usual one morning he surprised
him with his face in a basin of water, which he alternately drew up
and expelled fi'om his nose, with a view " to clearing out his head,"
as he thought. He was desired to desist from this, by way of expe-
riment, for a few days. The discharge then ceased and has never
recurred.
That the discharge was simply the return of the in-
drawn water appears to me to be extremely open to
doubt. The capacity of the sinus is limited. It is incon-
ceivable that the inspiratory suction of the water in the
basin would draw it into the accessory cavities ; and it is
difiicult to understand how the fluid would take such
a circuitous direction instead of following the direct
channel into the pharynx. That the flow should be
» ' Brit. Med. Journ.,' 1878, vol. ii, p. 921.
RUPTUEED LYMPH TUBES.
95
entirely absent when the patient was on his back is not
in favour of its originating in the antrum, for in the
horizontal position the mouth of the cavity is on a much
lower level than it is when the head is simply bent
forward. Indeed, such a variety in the flow is much
more compatible with the clinical pictures which have
preceded on the escape of cerebro-spinal fluid ; the one-
sided watery discharge, increased by bending forward
and ceasing in the upright and horizontal posture (? flow
into throat), the headache, the apparent absence of intra-
nasal changes, and of such symptoms as lachrymation,
sneezing, &c., are all compatible with the hypothesis that
the fluid may have been of intra-cranial origin.
Diagnosis feom Yaso-motor Neuritis.
In his cases of nasal hydrorrhoea Bosworth includes a
reference to the case published by Althaas in the
* Medico-Chirurgical Transactions,^ 1869, vol. lii, p. 27.
The hypersecretion of liquid in this case was attributed
by the author to the removal of the inhibitory influence
of the trifacial, so as to allow the sympathetic fibres to
reign supreme. The hypersecretion occurred not only
in the nose, but also in the eye and mouth. In the
' British Medical Journal ' for December 7th, 1878,
Althaus suggests that Sir James Paget^s case was pro-
bably one of injury or inflammation of the nasal twig of
the ophthalmic branch of the fifth nerve, and that the
" headache " from which the patient suffered shortly
before the flow commenced was a symptom of neuritis of
that twig.
Diagnosis prom Ruptured Lymph Tubes.
Ai'e there any other possible suggestions which might
be entertained as to the origin of this fluid ? The idea
96
THE CEREBRO-SPINAL FLUID.
was put forward by Mules, Avriting in 1888, that the
dropping from the nose in some of these cases was due
to the rupture of over-distended lymph tubes in the
pituitary membrane.
Mules (Manchester). — Lymph Ngevus and other Lym-
phatic Derangements of the Eye and its Appendages,'^
' Siebenter periodischer Internationaler Ophthalmo-
logen-Congress,' Heidelberg, 1888. Bericht, S. 467.
The writer holds that the association of persistent dropping of
fluid from the nostril with cerebral symptoms and optic nerve
atrophy is only accidental, and that the symptoms are in no way
interdependent. He narrates the following case : — A bright,
intelligent giri of eleven attended the Women's Hospital, Man-
chester, for a copious discharge of fluid fx'om the umbilicus, of six
months' continuance, no visible fistula being present. Besides this,
for the last four weeks, fluid apparently identical with that from the
umbilicus had dropped from under the upper right lid. It was
found that at frequent but irregular intervals during the day and
night a fluid bearing all the physical characters of lymph oozed
from under the upper eyelid in the region of the lachrymal gland,
yet no care could detect its exact point of exit. The fluid was opa-
lescent though faintly muddy, and whilst usually dropping quickly,
occasionally ran in a stream. The amount lost in twenty-four
hours was variable, but may be estimated at from four to six ounces
or even more, the quantity depending much on the discharge from
the umbilicus. Lachyrmal stimulation failed to induce or increase
the flow. Dr. MacMunn, of Wolverhampton, reported that "it
agrees in all essentials with Priestley Smith's two recorded cases
Emry 8- Jones' case, and those mentioned by Leber." The specific
gravity was 1'006. The patient had normal vision with corrected
astigmatism ; no head symptoms ; the discharge still persists.
He further describes a case of congenital lympho-angioma of
the conjunctiva and brow " in a boy of 12, and that of an elderly
unmarried lady who complained of increasing weakness of sight, and
who was markedly emaciated. For three years she had suffered
from continuous diarrhoea ; she had had a prolapsed rectum three
raonths after the diarrhoea commenced. For three years her diarrhoea
had alternated with a watery discharge from the bowel, necessitating
the use of five or six diapers daily. " There was found just inside
the sphincter a pale pink lympho-angioma, the size of a small walnut,
with several minute fistulous openings, from which trickled a clear
RUPTURED LYMPH TUBES.
97
presumably pure lymph. Tlie growth was ligatured, and with its
removal the diarrhoea ceased and she rapidly recovered flesh, but
unfortunately with her, as is the case of those with dropping from
the nostril, with sudden arrest of the lymph-waste came alteration of
the vascular balance, and six weeks after the removal of the nsevus
an apoplectic attack occurred with permanent paresis of the left
side." He also suggests that the hypothesis of a lymph extravasa-
tion will explain many cases of sudden proptosis which appear and
pass away without apparent cause. He thinks that even the
proptosis of exophthalmic goitre may be due to a lymph congestion
amounting almost to stasis of the orbital lymph stream, the outcome
of vaso-motor paresis. He therefore concludes " that these taken
togetlier show that the nasal flow, over the source of which so much
debate has arisen, may be definitely considered to be a lymphorrhcea,
due to over-distended lymph-tubes of the pituitary membrane, which
by their bursting caused fistulous openings, the difficulty of finding
them post mortem being due to the fact that they collapse, and the
number of the valves precludes their demonstration by injection.'
He says that in the case of the girl " we know that the escaping
fluid is lymph, identical in character with the nasal dropping of the
other I'eputed cases, and the cerebro- spinal fluid." He is bi'ovight to
the conclusion " that hydrocephalus and polypi are accidental
associations of this lymphorrhcea; that the nerve atrophy is an
incident rather than a necessity."
Qualitative Examination of Mules' Case of Persistent Dropping Fluid
from the Orbit. By Dr. MacMimn.
Sp. gr. 1006.
Opalescent with heat and acetic acid.
Opalescent with heat and nitric acid.
Yiolet when boiled with Fehling (albumen).
Chlorides abundant.
Sulphates present.
Spectroscopically no bands except faint traces of oxyhsemoglobin
dne to accidental presence of blood and traces of sero-lutein.
Note A. — The absence of sugar in these cases has been made a
point, but according to Hoppe-Seyler sugar is not a normal con-
stituent of cerebro-spinal fluid, but is due to irritation of the brain
or cord.
Note B. — Exception may be taken by some to the inclusion of
cerebro-spinal fluid under the term " lymph." By lymph we under-
stand the fluid contained in the lymphatic vessels as well as the
liquid found in the extra-vascular spaces, such as the lacunae of con-
nective tissue or the interior of the great serous sacs, from which
the lymphatics originate or communicate.
G
98
THE CEREBRO-SPINAL FLUID.
Inasmucli as divers organs possess diffei'cnt separative power, so
lympb varies materially in composition, according to tbe region
from wbicli it is derived ; thus while lymph coagulates, as a rule,
into a soft, trembling jelly, Ludwig (quoted by Gorup, Beaanez's
' Lebrbuch,' p. 378 ; vide Gamgee, ' Physiological Chemistry,' p. 220)
points out what some of the above cases fully substantiate, that
*' some lymph does not coagulate at all," but is identical in appear-
ance and composition Avith cerebro- spinal fluid, the fibrin or co-
agulating substance being due to its further elaboration in the
glands.
Difference between Lymph and Cerbbro-spinal Fldid.
The above suggestion of Mules may liave been worthy
of consideration at the date it was written (1888), but the
further progress of the chemistry of the cerebro-spinal
fluid — for which we are chiefly indebted to Halliburton —
has rendered it untenable.
In his well-known text-book^ Halliburton points out
that the cerebro-spinal fluid is not a serous exudation,
because (1) the arachnoid membrane is not a serous mem-
brane, either from the point of view of embryology or
structure ; (2) the fluid is not a mere lymph moistening the
parts already enumerated, but is normally present in
sufiicient quantity to exercise a considerable amount of
pressure ; (3) chemical examination of the fluid itself
shows that it is very different from the fluids contained
in serous membranes, and thus support is lent to the idea
originally propounded by C. Schmidt, that the fluid
should be classified rather with secretions than with
transudations.
On the other hand, lymph is an exudation ; it is like
blood-plasma in composition, only diluted so far as its
proteid constituents are concerned. There is no doubt
as to the presence of albumin in it ; it coagulates spon-
taneously, and the specific gravity varies from 1012 to
1022. It always gives all the tests for sugar. And in
human lymph the total proteids amount to ]3"66 per
1 ' A Text-book of Chemical Physiology and Pathology,' by W. D. Halli-
burton, London, 1891, p. 355.
ANALYSIS OP GROUP " B."
99
1000, i. e. about ten times tlie amount we find in Leber's
analysis.
Though the cerebro-spinal fluid is not lymph in the
chemical sense of the term, there is, however, no doubt
that its function is to serve as the lymph of the central
nervous system.
Some of the confusion in the above analyses may be
due to the accidental admixture with blood, which is
mentioned in some instances.
Summary of Evidence in Support op the Cases in
Group "B.''
The eight cases I have placed together in Group " A "
are undoubtedly instances of cerebro-spinal rhinorrhoea ;
they leave no room for question, and need not therefore
be further discussed. With regard to the twelve cases
in Group "B" I have eliminated the possibility of sug-
gesting that the flow originated from the Schneiderian
membrane, the lining of the accessory sinuses, or the
rupture of distended lymph-tubes. These considerations
have helped to narrow considerably the field of diagnosis,
but some positive indications will now be grouped
together to support the view that in all of them the
source of the fluid was the subdural and subarachnoid
cavities.
In eleven out of these twelve cases the fluid escaped in
considerable quantity. The amounts in the different cases
show a remarkable correspondence when we consider that
in the well-ascertained cases of Group " A " the rate of
flow was subject to some variation. Roughly estimated,
the maximum discharge in the twenty-four hours may be
placed on the average at half a litre (about 18 ounces).
When carefully measured, as in Case XVII, it is striking
that the quantity should so nearly approach that of my
own case (Case Vllj. The amounts given by King
(Case X) of a quart, and by Elliotson (Case XI) of three
100
THE CEREBRO-SPINAL FLUID.
quarts per day, appear to be based on unceitain calcula-
tions.
In eiglit instances it is mentioned that the flow was
one-sided, five times coming from the left and three times
from the right. Twice it alternated ; once it was more
from the left than from the right ; and once no mention
is made of the side most affected. In this preference for
the left side the majority of cases in Group " B " agree
with the positive cases of Group " A.'^
In five cases the flow continued by night as well as by
day. In only two cases is it recorded that the escape of
the fluid was not noticed at night. In five instances
there is no note on the subject, but doubtless if more
carefully observed it would have been discovered that in
sleep the liquid passed into the pharynx and was swallowed
unconsciously.
In four of the cases (XV, XVI, XVII, and XVIII) there
a remarkable similarity in the group of symptoms : per-
sistent dropping of a watery fluid from the nose, together
with long-continued severe brain symptoms, — such as
violent pains in the head, epileptic attacks, vomiting,
drowsiness, delirium, unconsciousness, weakness of the
legs, and extreme impairment of vision in both eyes
owing to optic neuritis or post-neuritic atrophy. This
clinical picture at once recalls Leber's case (II, A), which
was undoubtedly one of oorebro-spinal rhinorrhoea. In
four cases it is noted that the loss of vision was most
mai'ked in the eye on the side corresponding to the nasal
flow.
Nine out of the twelve cases suffered from symptoms
referable to the brain, varying from headache up to
giddiness, somnolence, vomiting, paralysis, convulsions,
and coma.
In each of the three fatal cases, as in the fatal cases
of Group " A," death was due to cerebral causes. Case
XII, B, has been so frequently referred to in literature
as a typical one of watery nasal discharge caused by
polypi in the antrum, and the high authority of Sir
ANALYSIS OP GROUP " b/'
lOJ
James Paget has evidently biassed observers so remark-
ably towards the same view^ that a somewhat fuller con-
sideration of his case appears needful. It is noteworthy
that the dropping was preceded by severe headache ; that
the flow was generally fairly uniform and continuous day
and night ; and that twice it ceased spontaneously, but
otherwise had shown no intermission during eighteen
months. In all these points it markedly resembles the
cases where the fluid came from the cranial cavity. The
question of its being from the antrum of Highmore has
already been so fully considered, that it need only be
pointed out that the fluid was like pure water, or the
fluid of the pia mater, or that of an accphalocyst : the
solid matters present were evidently accidental ; and the
physical aspect of the liquid — apart from the chemical
analysis — was much more indicative of the fluid being
produced by some secretory arrangement more highly
organised than the mucous lining of the maxillary sinus.
Laying aside for a moment the clinical and chemical
considerations, there is another point which weighs
against the suggestion that the rhinorrhoea was brought
about by the polypi in the antrum. This point is that as
polypoid degeneration of the lining of the maxillary sinus is
of frequent occurrence, it is remarkable that watery flow
from the nose is not more common. Besides, if the fluid
came from this cavity, why should it cease for the month
before the fatal attack ? The polypi, as evidenced by
the post-mortem, were still present to cause it. Finally,
the fatal meningitis, which could have uo relation to the
polypi in the antrum, becomes explicable as the evidence
points more strongly to the source of the fluid in
the cranial cavity. This view need not be abandoned
because no opening was found in the base of the skull,
for in Case YI, A," where there was an undoubted
solution of continuity in the base of the skull, the opening
is reported to have been " hardly perceptible." It is
pointed out by Leber ^ that we can iiaagine how small
1 Loc. cit.
102
THE CERRBRO-SPINAL FLUID.
snch communications may be when we remember tliat in
cases of pulsating exophthalmos it is generally impossible
with the most careful post-mortem examinations to detect
the true cause of this condition, viz. an abnormal com-
munication between the internal carotid and the cavernous
sinus. Nor need we abandon this view because the dura
mater covering the anterior fossa was healthy. Our
experience with secondary complications from diseases of
the middle ear frequently show that infection may be
carried to a distance while the intervening tract is, to the
naked eye, perfectl}^ healthy.
With regard to cerebral infections from the eye,
Devereux Marshall ^ records two cases of meningitis fol-
lowing excision of the eyeball for panophthalmitis which
show that the proximal region of the brain is not always
the part most invaded. In one case he says there was
no basal meningitis,^' and in the other " there was hardly
any meningitis seen at the base of the brain, but it was
most extensive in the convex surfaces of both hemi-
spheres.''
Several of these same conclusions may be advanced
with regard to the autopsy in Baxter's case (XV, B).
In the case of Speirs (XIV, B) the symptoms are all
so indicative of cerebro-spinal rhinorrhoea that it is suffi-
cient to direct attention to the description of them. The
suggestion that the goose-grease may have filled up the
communication between the nose and the antrum, leadinsr
to such alteration in the lining of the latter cavity as to
effect a cessation of the excessive secretion, hardly calls
for consideration. In this, as in several other instances,
it is necessary to bear in mind that the bibliography of
the subject is now sufficient to show that spontaneous
cessation of the flow takes place at the most unexpected
times and for no apparent reason.
Although some of the symptoms in Lichtwitz's case
(XXI, B) were suggestive of ordinary nasal hydrorrhoea,
1 The 'Roy. Loiul. Oplitli. Hosp. Repts.,' December, 1896, p. 312, Cases
II and IV.
CLINICAL PICTURE.
103
still one profuse watery flow (entirely from one nostril)
was unattended by headache or lachrymation. It is
extremely rare for vaso-motor rhinitis to be limited to
one side : it is inconceivable, as has been shown, that
the frontal sinus of one side could secrete such enormous
quantities of fluid ; and it is to be particularly noted that
the tappings of the sinus did not evacuate any clear
fluid. The flow was evidently as profuse as ever after
the puncture of the sinus, and as the permanent arrest
of the secretion only took place one year subsequently,
it can hardly be attributed to the treatment of the frontal
cavity. On the other hand, the di;ignosis of cerebro-
spinal rhinorrhoea appears to me much more likely for
the following reasons : pains in the head ; ocular trouble ;
one-sidedness and great profusion of discharge ; persist-
ence during the night ; the liquid being clear as water,
and not stiffening linen.
Clinical Picture.
Granting that the twelve cases collected under Table
B " were instances of cerebro-spinal rhinorrhoea, and
placing them alongside of my own and the other eight
undoubted cases in Table ^'A,^' what is the clinical
picture formed by comparing and contrasting the several
records ? The first point is that the sub-arachnoid fluid
can escape through the nose, without trauma or new
growth to explain how it effects an exit. This occurrence
happens with equal frequency in both sexes. It is an
affection of middle life, the age incidence falling between
the extremes of eighteen and sixty-five. The flow, in
most cases, commences gradually ; it occurs in drops,
much as the flow of blood in epistaxis ; and in carefully
recorded cases it is continuous both by day and by night ;
in the latter period it may be swallowed during sleep. It
generally makes its escape from one nostril only, but
may flow from both. The fluid which escapes amounts
104
THE CEREBRO-SPINAL FLUID.
to about half a litre in twenty-four hours ; it is as clear
and limpid as spring water, perfectly free from odour,
and tasteless, or only slightly salt. The quantity
which may escape in one day is, in itself, no positive
evidence of a nasal flux being cerebro-spinal in origin ;
for Boswortli reckons that in one of his cases, apparently
one of true hydrorrhoea uasalis, the secretion amounted
to a pint in the day. The quantity of cerebro-spinal
fluid is increased when the patient strains in any way, or
hangs the head forward ; it is said to be inci'eased during
a cold, but this is probably only due to the admixture of
ordinary mucus. If collected with care the fluid is found
to be absolutely sterile. A superficial examination would
show that it is faintly alkaline, with a specific gravity of
1005, that it gives a slight opalescence on boiling, that
it reduces Fehling's solution, but the fermentation test
proves that this is not due to sugar.
The following is a list of the reactions which determine
the cerebro-spinal character of the fluid.
Chemical Tests for Cerehro-spinal Fluid.
1. The fluid is perfectly transparent like water, and
contains no sediment,
2. It is faintly alkaline in reaction, and either tasteless
or slightly salt.
3. The specific gravity is between 1005 and 1010.
4. It is not viscous, and gives no precipitate (mucin)
on adding acetic acid.
5. On boiling there is not more than a trace of
coagulum of serum globulin. Serum albumin is usually
absent, for after saturating with magnesium sulphate and
filtering off the precipitated globulin, no proteid is found
in the filtrate.
6. When boiled with Fehling's solution reduction takes
place.
CHEMICAL TESTS.
105
7. The reducing substance may be obtained by eva-
porating to dryness an alcoliolic extract of the fluid. It
is then found in the form of needle-like crystals {vide
Plate, p. 19).
8. The aqueous solution of this residue does not ferment
with yeastj and does nor give the phenyl-hydrazine re-
action.-^
These tests are quite sufficient to show that the re-
ducing substance is not sugar. Although its exact
composition is still unsettled, it is possibly related to
pyrocatechiu.
If applied to suspected cases, these tests will, in future,
avoid any question as to the true nature of cei'ebro-spinal
fluid when it escapes from the nose. Confusion and
uncertainty may have been brought about, in the past, by
observers basing their knowledge on the character of
this fluid in diseased conditious. For instance, in hydro-
cephalus, especially if there is any inflammation, the
specific gravity is higher, and the amount of albuminous
matter greater. In general paralysis of the insane there
is no reducing substance, but a large increase of proteid
or albuminous matter, and a substance alkaloidal in nature
(choline from the degenerated brain-cells), which markedly
reduces blood-pressure (Mott and Halliburton^).
These cases confirm the opinion of Magendie that
cerebro-spinal fluid is reproduced with great rapidity.
This is interesting in view of Foster's statement that
" the quantity present in the subarachnoid space of the
cranial cavity is small, probably not exceeding 2 c.c.
under normal circumstances ; there is a larger quantity
in the spinal canal." Leonard Hill* found experi-
mentally that removal of the cerebro-spinal gives place
^ The phenyl-h_\ diaziiie test consists iu boiling a suspected liquid for half
an hour with small quantities of phenjl-hydniziiie hydrochloride, and sodium
acetate. If sugar is present, yellow crystals of csazone are formed.
' • Proceeds. Physiol. See.,' February, 1897, and February, 1898.
3 'Text-book of Physiology,' 7th edit., 1897.
'The Physiology and Patliology of the Cerebral Circulation,' Loudon,
189G
106
THE CEHEBRO-SPINAL FLUID.
to a serous transudation, and Foster ^ is of opinion tliat
when the fluid is quickly formed its peculiarities dis-
appear, and it then acquires the characters of an ordinary
serous exudation. It does not appear to he so in my c;ise,
so that the conclusion is suggested that in the present
instance the secretion takes place under peculiar con-
ditions.
These cases also show that a draining away of this
fluid may continue during several years, without exerting
the slightest appreciable effect on the functions of the
central nervous system. Inter alia it may be noted
that the perilymph and endolymph apparently must be
kept at a certain tension for the proper performance of
their conducting function. Now the cavity which con-
tains the perilymph communicates through the sheath of
the auditory nerve with both the subdural and subarach-
noid spaces.^ In none of the above twenty-one cases do
aural troubles seem to have been induced by alterations
of tension in the labyrinth consequent on this nasal
flow.
Of seventeen cases where it has been carefully observed
which nostril was affected, it has been noted in ten that the
escape took place entirely from the left side. What is the
significance of this apparent preference for the left side ?
Does it depend on the same causes which lead to the
rare condition of unilateral destruction of the olfactory
bulb with anosmia ? In these the left bulb has always
been the one affected. {' System of Medicine,' edited
by Clifford Allbutt, 1898, vol. iv, p. 695.) But yet the
fluid may escape from both nostrils (Case VI), although
the communication with the cranial cavity only existed on
one side.
Examination of the interior of the affected nostril
reveals nothing more than slight excoriation of the naris,
and some intumescence of the middle turbinal. If the
escape is carefully watched it is found to take place
' ' Text-book of Physiology,' 7tli edit., 1897.
2 'Quain's Anatomy,' 10th edit., 1894, vol. iii, pt. ill, p. 104.
CLINICAL PICTURE.
107
between the middle turbinal and the septum^ and there-
fore from a higher region than the openings of the
maxillar}^ or frontal sinuses and the anterior ethmoidal
cells. Of course this cerebro-spinal rhinorrhoea may
occur when other conditions are present in the nose or
its accessory cavities, sind the consequent complication of
symptoms should be borne in mind. The long-continued
soaking of the mucous membrane in fluid uiay conduce to
the secondary formation of mucous polypi.
From other discharges from the nose, cerebro-spinal
fluid can be distinguished not only by the physical and
chemical characters alread}^ given, but also by the manner
of its flow. It is generally one-sided. Although it may
occasionally give rise to a little sneezing, especially in
the morning or on changing position, this is a rare and
infrequent accompaniment. It is not accompanied with
lachrymation, or suffusion of the conjunctiva and photo-
phobia. Although it rarely intermits, it is practically a
continuous flow, varying slightly in amount under the
influence of straining and posture. It appears to be un-
influenced by external conditions or by the general state
of health. In these several points it contrasts markedly
with hay fever, paroxysmal sneezing, vaso-motor rhinitis,
&c.
Most of these latter affections are also accompanied
with more or less prostration and lassitude, the patient
always feeling worse when the flow is taking place, and
experiencing relief only when it ceases. It is a curious
and noteworthy fact that in a large number of instances
of cerebro-spinal rhinorrlicea cerebral symptoms are pre-
sent, but they precede the flow, and are, as a rule, re-
markable by their cessation while the fluid is escaping.
The headache which in some cases was present before the
onset of the flow, nearly always recurs when the flow
diminishes or intermits.
It is important to bear in mind that the flow may
spontaneously cease for periods varying from a few hours
to several months. In some cases it has spontaneously
108
THIO CER15BR0-SP1NAL FLUID.
ceased altogether, or at least it had not recurred after an
intermission of five or even fourteen years. Such cessations
of the flow must be watched with suspicion, for recurrence
has taken place even after an intermission of fourteen
years.
These cessations are numerous enough to make us chary
in attributing a cure to any form of treatment we may be
employing.
A certain number of these cases are associated with
ocular affections. In some instances (6) affections of
sight are complained of before any dropping from the
nose appears, but in others (2) the dropping has been
going on for some time before the eyes become affected.
The ocular lesion generally takes the form of retinitis and
optic nerve atrophy.
This bizarre affection has been known to endure for
five years in a well-authenticated instance (Case VII A),
and for twelve years in a possible case (Case XIX B). Tlie
cerebral symptoms which have been associated with the
flow are also remarkable for their occurrence in connec-
tion with the fatal termination of some of the cases. In
the cases where there is a record of the fatal termination
— in six out of twenty-one cases — it was in every in-
stance due to cerebral complications — although we must
observe that in one case (VI B) this was undoubtedly con-
nected with surgical interference.
The post-mortem in this case showed that the escape
in life had taken place through a small hole in the dura
mater, alongside the apophysis crista galli. Of the other
instance where death took place with cerebral symptoms, we
have only the statement of the fact iu two cases ; in two other
cases, although gross lesions were found in the brain and
membranes, no connection could be found with the nose,
and in another case the result of the post-mortem exami-
nation was entirely negative. Possibly it may have been
overlooked in these last three cases, for the cerebro-spinal
origin of the fluid had not been diagnosed in either of them,
and in the above case (VI A), where the communication
PATHOLOGY.
109
between the cranium and nose was found, it is reported
to have been " hardly perceptible." There are no records
of death from any other complications.
Pathology.
Leber regarded his case (II) as undoubtedly one
of hydrocephalus internus, in which the ossification of
the skull lead to increased intra-cranial pressure. The
other six cases to which he was able to refer (Cases XI,
XII, XV, XVI, XVII, XVIII) at the date of his publica-
tion (1883) he ascribes to a late hydrocephalus, although
he allowed there was no direct evidence of this. But he
records the case of a young woman where von Graefe
made the diagnosis of a neuritis descendens conse-
quent on a meningitis of the base of the skull. There
was no question of hydrocephalus during life, and
the post-mortem revealed no trace of meningitis or
tumour, but, instead, a high degree of hydrocephalus
with marked flattening of the corpora quadrigemina and
simple atrophy of the optic nerves. He also refers to a
patient of Forster's ^ who suffered from attacks of giddi-
ness, convulsions, and vomiting, and gradually became
blind, where the post-mortem examination showed con-
siderable dropsy of the lateral ventricles and such a
decided expansion of the middle ventricle that its floor
projected like a bladder from the base of the brain so
that the optic tract and chiasma were quite flattened out.
Such cases, he writes, may be amongst those where
meningitis is sometimes suspected, but recovery takes
place. When such attacks recur we suspect the existence
of a cerebral tumour, though this suspicion is abandoned
when blindness continues for years with tolerably good
health. Other factors which point towards hydrocephalus,
and away from tumour, are the long duration of the
1 " Zur Pathologic des Gehirns," ' Virchow's Avchiv,' Bd. xiii, 1858.
110
THE CEHEBRO-SPINAL FLUID.
illness in most cases, and the constant absence of sym-
ptoms pointing to one locality.
It is mentioned by Sir Thomas Watson ^ that hydro-
cephalus does occasionally commence long al'ter the skull
has become a complete case of bone. Ho quotes several
cases, and amongst others that of Dean Swift, who is said
to have died of this complaint in 1745, after an illness of
three years' duration.
The hydrocephalus of adult life, or chronic meningo-
ependymitis, is referred to in the last edition of Hilton
Fagge's and Pye-Smith's ' Principles and Practice of
Medicine,' vol. i, 1891, p. 672. Several cases are given,
in all of which the ventricles were dilated with fluid ; but
it is said that the membranes at the base were frequently
found thickened, opaque, and matted together, even
more so in the affection of adults than in that of children.
This does not agree with the description given by Quincke ;
and although in some cases the bilateral symptoms might
suggest the nature of the disease, still hemiplegia was
occasionally present and made the diagnosis from other
chronic cerebral diseases exceedingly difficult if not
impossible. Huguenin's attempt to give a systematic
account of the disease affords additional proof of the
variety of aspects that ic may assume.^
Dercum^ gives a very short notice of this affection, and
states that there is nothing sufficiently characteristic in
the symptoms to enable one to form a positive diagnosis.
He says the presence of the disease may be surmised, but
not determined.
Several cases of serous meningitis, or primary idio-
pathic hydrocephalus, have been reported by different
writers (Eichorst, Oppenheim, Annuske), but for our
clinical knowledge we are chiefly indebted to Quincke.^
' 'The Principles aud Practice of Physic,' 4th edit., London, vol. i, 1857,
p. 464.
2 ' Ziemssen's Handbuch der Krankheiten des Nerve nsystems,' Leipzig, 1876.
5 ' Text-book of Nervous Diseases,' 1895.
'Volkmann's Sammhing,' 1893, No. 67, and ' Deuts. Zeitsch. f. Nerven-
heilkunde,' 1896, ix, p. 149.
HTDKOCEPHALUS INTERNDS.
Ill
In Oppenheim's text-book there is a clear account of the
affection, but the references to it in English literature are
so brief and insufficient that the following sketch of the
disease, in so far as the symptoms bear on the question
under discussion, is taken from Quincke's articles.^
This description may be a little beside the main question
I am concerned with, but still it deals with a condition
which, I think, is sure to suggest itself in connection
with the pathology of cerebro-spinal rhinorrhcea.
Hydrocephalus Internus.
The central idea of the disease is that we may have a
serous as well as a purulent meningitis. Hitherto it has
been customary to recognise only meningitis in a purulent
form ; but Quincke holds that a meningitis, particularly
an ependymitis, may give rise to a simple serous effusion,
as well as a purulent one ; in this way meningitis becomes
analogous, in its two forms, to the inflammations of other
membranes — the pleura, pericardium, and synovial mem-
branes. As such a meningitis may occur at all ages, and
give rise to collections of fluid in the ventricles, we may
have a primary idiopathic internal hydrocephalus of
adults, as well as the classical form of children. The
disease may be either acute or chronic ; tlie acute cases
are frequently mistaken for purulent meningitis, and the
chronic ones for cerebral tumour. In another variety of
the chronic form, according to Quincke, the symptoms are
those of neurasthenia. The conclusive proof of an autopsy
is necessarily lacking in the neurasthenic form, and even
when at the autopsy an effusion is found, it is not custo-
marily regarded as pathologically a sufficient cause of the
symptoms or of death.
The acute forua may run a rapid course throughout ; or
1 For several of these references I am indebted to an article by Morton
Prince on " Idiopathic Internal Hydrocephalus (Serous Meningitis) in the
Adultj" with reports of three cases, in 'The Journal of Nervous and Mental
Disease/ vol. xxiv, August, 1897, No. 8, p. 473.
112
THE CERKBRO-SPJNAL FJ.UID.
alter a course of some weeks it may end in complete or
incomplete recovery or death, or become chronic. The
chronic form may pursue a varying course, with occasional
acute exacerbations. In both classes a remaining optic
atrophy may be the sole indication of past cerebral
disease.
The symptoms, as in other brain affections, are general
and local, and depend largely upon increase of pressure.
The local symptoms are pai'alysis (especially of the cranial
nerves), exophthalmos, cervical pain and rigidity, hyper-
aesthesia, pain in the extremities, &c. It is by its course,
and greater or less intensity of individual symptoms, that
it is to be distinguished from other forms of meningitis
and tumour. Fever is either absent or only slight, of
short duration,, and irregular course. The headache is
diffuse or located in the foi'ehead or occiput, of varying
intensity, and sometimes periodic, or with periodic exacer-
bations. The headache may be associated with unrest,
delirium, or sleeplessness. It is only in fatal cases that
dulness of consciousness becomes continuous and profound.
Vomiting is common. Rigidity of the neck, with tender-
ness and pain on motion, may be prominent. Paralysis of
the ocular and facial nerves may be present, though not
usual; that of the sixth is most common, as it is most
exposed to pressure on account of its course. These
paralyses are apt to be slight and of varying intensity.
The pupils are unequal and react slowly, or are stable.
More or less diffuse spasms may occur. A most impor-
tant symptom is optic neuritis, with atrophy. This is
more frequent than in other forms of meningitis. In the
chronic forms it is frequently associated with headache,
vomiting, and mental dulness as the cardinal symptoms,
thus simulating tumour ; but after weeks or months such
cases may end in recovery. The visual defect, instead of
blindness, may be that of bitemporal hemianopsia, due
to pressure from the dilated third ventricle upon the
optic chiasma. Other symptoms are exophthalmos and
cutaneous hyperaesthesia.
HYDROCEPHALUS INTERNUS.
113
For the diagnosis, which at present in most cases must
be extremely difficult, Quincke lays stress on the great
variations in the intensity of the symptoms from day to
day ; at one time one symptom, at another time another,
coming to the foreground. In the chronic cases the
occurrence of remissions and intermissions must largely
he relied upon to distinguish them from tumour, and
when the rare focal symptoms (palsies, &c.) are present,
the fact that instead of progressively deepening as with
tumour, these symptoms have a temporary or varying
existence.
As to the pathology of serous meningitis, the post-
mortem results are for the most part limited to the
accumulation in the ventricles of clear fluid which shows
no material difference from the normal. It is pointed
out by Quincke that while the effusion from cortical
meningitis is almost always turbid, and therefore more or
less rich in cellular elements and albumin, the reverse is
the case in meningitis of the ventricles. The ventricles
may be enormously distended, so that tho convolutions
may be flattened and the sulci appear obliterated. In
the acute form the changes in the ependyma may be
limited to hyperaemia ; in the cl)ronic form the only
alteration may be some slight thickening and change in
texture, described as smooth, velvety, granular or sodden.
The pia mater may also be hyperaemic, and share some-
what in the process. In discussing the pathogenesis,
Quincke likens the affection to acute angio-neurotic oedema
of the skin (Quincke^s disease), an analogy which renders
intelligible the sudden development and variability of the
symptoms observed.
In three cases fully described by Morton Prince ^ the
symptoms were those embraced by the above clinical
picture, but they were also most remarkable for their
variety and variability. In two cases a post-mortem was
obtained, and although the naked-eye appearances were
those already given, it is noteworthy that in one case even
' Loc. cib.
H
114
THE CEREBRO-SPINAL FLUID.
a microscopical examination failed to reveal what are
usually regarded as evidences of inflammation. Morton
Prince, in view of tliese two autopsies and other findings,
expresses the opinion that it seems questionable if the
disease process is to be regarded as an inflammation. He
considers that the pathology of the disease must still be
regarded as obscure, and that it invites further investiga-
tion.
With regard to the above picture by Quincke, it is to be
regretted that the terms meningitis and " serous " have
been employed in conditions where they are not applicable.
Firstly, because in the most typical cases there are no
evidences of inflammation of the meninges; and secondly,
because there is no such thing as serum in the living body.
That liquid is a product of the death {%. e. coagulation) of
the blood. Then the suggested analogy of the condition
to inflammation of other membranes — the pleura, peri-
cardium, and synovial membranes — is hardly justifiable,
for the distinctions between the serous membranes and
lymph, and the arachnoid membrane and cerebro-spinal
fluid, have already been pointed out (p. 98).^
Still, after allowing for these two objections, the above
sketch of the hydrocephalus of adults appears to justify
at least a consideration of the suspicion that the twenty-
one cases I have collected may have been instances of this
disease.
The Gerehral Symptoms in the Majority of the Twenty-one
Gases.
It has already been pointed out that in no less than
seventeen cases there were cerebral symptoms ; two cases
are reported so inadequately that it is possible that slight
nervous troubles may have been overlooked ; and in only
one case (Emrys- Jones, XIX) have we a note as to the ab-
sence of all headache. In the seventeen cases the cerebral
symptoms varied from headache to giddiness, severe
' Halliburton, ' Jourual of Physiology,' vol. x, No. 4.
THE CEREBRAL SYMPTOMS.
115
headache^ heaviness, somnolence, drowsiness, vomiting,
delirium, convulsions, and coma. Paretic symptoms were
noted in four cases (IX, XVI, XVIII, XX). In eight
cases the eyesight was affected, there being optic neuritis
or atrophy. In one case there was proptosis. In one
there was slight prominence. Enlargement of the thyroid
was noted (XV). Vomiting was present in three cases
(XV, XVII, XVIII). A striking point in which all the
twenty-one cases appear to agree is in the absence
of fever ; but the rigidity of the neck and cervical pain,
which Quincke says " may be prominent," do not appear
to have been observed in any case. This, however, is
easily understood if we may conclude that the effusion in
all these twenty-one cases — judgiug from the escape of it
through the nose — took place chiefly into the anterior
fossa. Priestley Smith's second case (XVIII) very
markedly resembles the picture of the acute form of serous
meningitis passing into the chronic form. And Baxter's
case (XV) is a striking example of " diffuse spasms "
and neurotic symptoms. These neurotic symptoms appear
to have been present in several cases ; my own patient
was thought by her medical attendant and her friends to
be " rather hysterical ; " and no doubt symptoms in
several cases were put down to a neurasthenic constitution
owing to their very variable character. This changeable
character in the symptoms, the absence of any well-
localised cerebral phenomena, the duration of the disease,
and the arrest of the nasal flow for long periods, or even
complete disappearance, all point towards the hypothesis
of hydrocephalus and away from any suspicion of cerebral
tumour. The post-mortem examinations in four of these
cases give no positive evidence against the plausibility
of this theory. The first case (V) is of value in a nega-
tive way, as it shows the absence of localised disease.
In the second (VI) the results of the autopsy are a
little confused, as the patient died from traumatic infection
of the meninges. Paget's case (XII) also suffers from
the pathological condition having been overlaid with
116
THE CEREBRO-SPINAL FLUID.
secondary infection ; but in Baxter^s (XV) the negative
finding only bears out Quincke's view.
Finally^ the fact that in most cases the head symptoms
preceded the nasal flow^ were always relieved by it, and
generally recurred whenever it diminished, suggest that
an internal hydrocephalus may be the diseased condition
of which cerebro-spinal rhinorrhoea is one occasional con-
sequence and symptom.
I do not wish to insist too strongly upon the similarity
between the phenomena in the above twenty-one cases,
and the symptoms grouped together by Quincke and others
as indicative of the primary idiopathic hydrocephalus of
adults. I believe the latter affection has still to justify
its identity; and it is, of course, possible that — always
excluding trauma and tumour — cerebro-spinal fluid may
make its escape into the nose under diffei'ent conditions.
We have to bear in mind, also, and on the authority of
Hughlings Jackson,^ that " there are no symptoms known
to be characteristic of meningitis only." The hypothesis
is therefore only suggested as a provisional one. Even
if proved untenable it may serve to direct attention to
the frequent association of cerebro-spinal rhinorrhoea with
cerebral and ocular conditions which have not been satis-
factorily explained.
Route op Exit feom the Cranial Cavity.
As to the method in which this flow makes its escape
from the cranium we have very few facts to go upon,
and any conclusions must largely be matters of conjecture.
The condition is evidently not a congenital one. Still,
many of the symptoms would be quite consonant with a
small congenital meningocele situated in the region of the
cribriform plate of the ethmoid, and rupturing into the
nose under some exceptional pressure. This might
1 'Trans. Ophth. Soc.,' vol. i, 1881, p. 72.
EXIT FROM THE CRANIAL CAVITY.
117
explain tlie premonitory headache and the relief experi-
enced on the establishment of the flow. But to such a
theory it could be replied that there was uo history of
sudden preceding strain in any of the cases, and in those
which were completed by an autopsy no trace of such a
meningocele was to be discovered.
Another possible explanation is that it might be brought
about by an anomalous development of a physiological
communication between the subarachnoid space and the
lymph channels of the nose. This anastomosis was first
demonstrated by Schwalbe/ who succeeded in injecting
the lymphatic vessels of the nasal mucosa from the
subdural space. His experiments were made on animals,
as were also those of Key and Retzius/ whose results
tend to show that there is an open communication between
the external air and the subarachnoid space. On inject-
ing a coloured fluid, under feeble pressure, into the
latter cavity the lymphatic spaces of the nasal mucous
membrane were seen to be distended with the same fluid.
The fluid not only accompanied the perineural sheaths,
but also filled the lymphatic network which is altogether
independent of the nerve sheaths. Indeed, Retzius
claimed that on examining the cribriform plate he could
observe fine canaliculi into which the meninges sent very
thin prolongations, and quite independent of the canals
for the nerves. Vertical sections of the injected olfactory
mucosa showed that the coloured lymphatic ramifications
traverse the epithelial layer to open on the very surface.
It is well to remember that this anastomosis has not
been demonstrated in man, and to bear in mind the
criticism of Zuckerkandl that we ought to be able to
anatomically demonstrate the transition from the one
system to the other, in order to meet the objection that
the communication was made through the rupture of the
pia mater under the pressure of the injection.
^ " Der Arachno'ulalraura eiii Lymphraiim, &c.," * Centralb. f. d. nied. Wis-
senschaften,' 1869, No. 30, s. 465.
2 'Stud, iiber d. Anat. d, Nervensyst., &c.,' Stockholm, 1875.
118
THE CEREBRO- SPINAL FLUID.
Flatau publishes in tlie ' Deut. med. Woch.,' October
30th, 1890/ an account of his experiments on the com-
munication of the nasal lymph passages with the sub-
arachnoid space. He states that Naunyn and Schreiber
were able to inject warm salt solution into the sub-
arachnoid space of the dog and make it come out at the
nose, the phenomenon being accompanied by protrusion
of the eye and chemosis. Flatau proves the correctness
of these experiments by injection experiments of his own,
but finds that, although injections into the subarachnoid
space reached the nose, the injection of coloured fluid
into the nose did not, however, lead to an entrance of the
fluid into the arachnoid space. This he attributes to the
barrier presented by the columnar epithelium. His
experiments were made on rabbits and cats.
Nothnagel (p. 68) favours the view that the escape
may be along the perineural sheaths, since in his case the
sense of smell was lost and there was atrophy from pres-
sure of the olfactory fibres. But anosmia does not appear
to have been at all characteristic of the twenty- one tabu-
lated cases.
The cerebro-spinal fluid may escape into other cavities
besides the nasal fossas without any obvious cause, such as
fracture, to produce it.
The following I observation of Vieusse ^ led him to the
diagnosis that it is possible for an accidental opening to
take place through the sphenoidal fissure, so placing in
communication the capsule of Tenon and the cavity which
contains the cerebro-spinal fluid, so that through this
opening the liquid entered and made its exit from the
orbital cavity, according to the position of the head.
A soldier presented himself for feebleness of vision in the left eye.
The difference of aspect presented by the two eyes was striking.
The right eye appeai-ed normal, while the left globe seemed buried
in an orbit with very prominent margins. On placing the finger on
* From Sajous' ' Annual of the Universal Medical Sciences,' vol. iv, 1891.
2 • Gazette Hebd. de Medecine et de Chirurgie,' tome xvi, 1879, No. 19,
p. 299.
EXIT PROM THE CRANIAL CAVITY.
119
the globe of the eye and pressing lightly, one felt that the sohd
organ escaped and appeared to retreat into the back of the orbit,
without giving rise to the least phenomenon of cerebral compression.
Movement is normal and identical in both eyes ; no deviation and
no double vision. Hence it may be concluded that the fatty tissue
in the left orbit has been absorbed, apparently by simple atrophy
as in old age. Another point was that the eye changed its position
according to the position of the head. When the head was bent
forwards for a few seconds the eye became prominent, and the dis-
tended lids and congested conjunctivae suggested a complete ex-
ophthalmos. The sight at the same time disappeared. On raising
the head to the horizontal position, this state of affairs disappeared
quickly, the eye resumed its normal primitive aspect and retreated
into the orbit. The observation was repeated several times, and on
no occasion was it possible to detect with the finger any throbbing
or pulsations in the eyeball.
According to the patient's account he had never suffered from
any head symptoms. He attributed the condition to his occupation
as a carpenter, which caused movements of his head.
It is noteworthy that the return of fluid into the cavity
of the skull did not induce any cerebral symptoms, such
as occur in some of my cases when the flow ceased.
Finally, we have only the one post-mortem to appeal to
to show that the fluid may escape through an " almost
imperceptible " hole in the cribriform plate beside the
crista galli. How this opening was caused I am unable
to explain, nor why the flow should so frequently occur
on the left side. It could not be attributed to a weak spot
left by disproportionate growth during the course of deve-
lopment, for in several cases the flow commenced long after
complete maturity. There might have been a congenital
defect in the bone, the membranes covering it yielding
after a time to continued pressure.
A simple solution of continuity in the base of the skull,
arising in some unknown manner, may be the only ex-
planation at present. It has been shown that this may
occur into the external auditory meatus (p. 6), into the
orbital cavity (p. 118), through the cribriform plate
of the ethmoid (Case VI), or by way of the frontal (Case
XIX) or other sjnuses.
120
THE CEREBRO-SPINAL FLUID.
But in view of the frequent association of cerebi'al and
ocular symptoms, and of the increase or recurrence of the
former when the dropping ceases, I do not feel disposed
to rest content with the suggestion that we have simply
to do with a " leakage " through some accidental fissure.
Treatment.
As to the treatment I have, unfortunately, nothing to
suggest. Until we know more about the pathology of the
affection I should think it is desirable to refrain from anj''
direct attempt to check the flow. The administration of
powerful revulsives, the internal administration of large
doses of ergot and other astringents, have proved utterly
useless. Against the intra-nasal medication I would
venture to particularly urge a warning. First of all, it
is extremely doubtful if fluids spraj^ed or injected into
the nose can reach the superior meatus where, presumably,
the cerebro-spinal fluid makes it entry into the nose.
Secondly, unless administered with strict aseptic precau-
tions, the use of nose lotions certainly exposes the patient
to the risk of infection of the fluid, and consequent
meningo-encephalitis. And thirdly, if it is for the pro-
tection of the patient from ulterior consequences, the
spraying of mild antiseptic solutions into the nose is
quite uncalled for. Not only, as I have already said,
does the nasal mucous membrane, in the absence of intra-
nasal disease, provide for its own asepsis, but, as I have
elsewhere pointed out,^ no fluid sufficiently antiseptic to
be of value could be used on such a sensitive surface as
the Schneiderian membrane.
I think that while we may encourage the patient in
the hope of the cessation of this troublesome dropping,
we should clearly advise him against attempts to sum-
marily check it, and, until our knowledge of the subject
increases, to some extent explain to him, so far as he is
' " L'Antisepsie et les Medications lutra-nasales," ' Ann. dos Mai. de
rOreille, ^c.,' January, 1895.
CONCLUSION.
121
likely to understand the question, some of tlie peculiarities
of his case.
It has been suggested that the advisability of trying
lumbar puncture is well worth considering in ray case.
Conclusion.
The record of one case in full, and the collecting
together of these twenty others will, I trust, stimulate
investigation of the subject. From the data given, the
diagnosis of the condition can now present no difficulty,
and I would suggest that all future cases should be kept
under careful observation. "When opportunity for a post-
mortem does occur, needless to say that attention should
be most carefully directed to the roof of the nose and the
anterior fossa of the skull. It would not be sufficient to
submit the floor of the skull to a naked-eye inspection ;
the fossa should be filled with coloured fluid and careful
note made as to how it passes into the nose. The con-
nection might possibly be traced via the orbit. Indeed,
other factors will doubtless be brought to our knowledge
which have escaped my observation or been absent in my
case.
This publication will, I hope, have earned an excuse
for its length by finally establishing a hitherto unrecog-
nised pathological possibility. As in so many other affec-
tions at first recorded as "rare," it may be found that
cerebro-spinal rhinorrhcea is only rare from not having
been carefully looked for. Its recognition is not only of
importance to the general physician, but in the present-
day subdivision of disease it will as likely present itself
to the neurologist and ophthalmologist as to those inte-
rested in diseases of the throat and nose. It may help to
elucidate some hitherto obscure cases with cerebral sym-
ptoms, and certain unexplained instances of optic nerve
atrophy. While its recognition is of the utmost import-
ance, not the least interesting feature of the affection is
the opportunity it affords for the examination of fresh, and
122
THE CEREBRO-SPINAL FLUID.
apparently quite normal^ human cerebro-spinal fluid. Ex-
cepting the instance of Toison and Lenoble in 1891, my
present case is apparently the only one where such an
opportunity has presented itself. In view of the attention
being given at present to lumbo-sacral puncture, the
establishment of the exact physical, bacteriological, and
chemical constitution of fresh, normal, human cerebro-
spinal fluid is a point of considerable importance.
PAKT II.
OBSERVATIONS
ON THE
COMPOSITION AND FUNCTION
OF THE
CEREBRO-SPINAL FLUID IN THE HUMAN
SUBJECT.
OBSERVATIONS ON THE COMPOSITION AND
FUNCTION OF THE CEREBRO-SPINAL FLUID
IN THE HUMAN SUBJECT.
Characters of the Fluid.
In tlie preceding pages the general characteristics and
chemical properties of the cerebro-spinal fluid have been
sufficiently dwelt upon. A complete analysis of the liquid
will be found on page 17 ; its chemical composition is con-
sidered on page 86 ; the differences between lymph and
cerebro-spinal fluid are indicated on page 98 ; and a table
of chemical tests for the detection o£ cerebro-spinal fluid
is given on page 104.
On page 20 attention has been directed to the sterile
condition of the fluid, even after traversing the nose.
It has been pointed out (page 18) that the amount
secreted may be over half a litre per day.
COMPAEISON OP THE MOENING AND EvENING FlUID.
While studying the literature of this subject I came
across an interesting paper by Cavazzani.^ He carried out
a series of experiments on dogs in order to determine if the
chemical constitution of the cerebro-spinal fluid remained
the same after activity of the organism and after repose.
He therefore killed four dogs at six in the morning, and
' "Sul Liquido Cerebro-spinale," ' La Rifornia Medica,' anno viii, 1892,
vol. ii, p. 591.
126
THE CEREBRO-SPINAL FLUID.
four others at six in the evening ; in all particulars the
two sets of dogs were as alike as possible, and killed in
the same way. The small quantity of fluid obtainable
(1 to 4 grammes) limited the study to the reaction and
the amount of residual solids. The result was that the
fluid collected in the morning was more alkaline than
that in the evening ; on an average the alkalinity was
twice as much. Also, the morning fluid left a greater
solid residue than that of the evening. Cavazzani
suggests that this greater increase of solid residue and
alkalinity is related to the activity of the nervous system,
in view of the fact that between the morning and evening
observations there was no other difference than the inertia
of the nervous system. He does not think that the
question of muscular repose need be taken into account,
because the dogs were kept in a very small yard, and
their muscular activity amounted to very little.
From these observations he concludes that his results
constitute a demonstration of some value in favour of
Obersteiner's theory of sleep. According to this the
phenomenon of sleep is due to the accumulation of
reducing substances in the brain. The greater quantity
of solid residue met with in the morning cerebro-spinal
fluid is, therefore, according to Cavazzani, due to the
gradual elimination during the night of the substances
which have accumulated in the tissues of the nervous
centres during the activity of their waking hours.
He obtained corresponding results in the case of a man
with traumatic fistula of the frontal bone.
In view of these observations, I thought that my
patient's case presented an excellent opportunity for
repeating them in the human subject. The fluid was
therefore collected by the patient herself on several
days, and forwarded to Professor Halliburton in two
bottles, one containing the fluid collected the first thing
in the morning, and the other the fluid collected the last
thing in the evening.
The qualitative examination of the fluid collected on
EFFECT OF INTRA- VASCULAR INJECTION.
127
several mornings gave the same results as that of speci-
mens collected the last thing in the evening. Both were
distinctly alkaline, but no estimation of the relative alka-
linity was made. The following table gives in percentages
the results of the qualitative analyses :
Morning fluid. Evening fluid.
Water .... 99-004 . 99-027
Solids .... 0-996 . 0-973
Organic solids . . . 0-118 . 0-100
Inorganic solids . . 0-878 . 0-873
The evening fluid is thus slightly poorer in both
classes of constituents than that of the morning ; the dif-
ference is chiefly due to an alteration in the organic solids.
This is just what wo should expect, as the decreased
capillary pressure during sleep would lessen the rate of
exudation of water. Without comraittiug ourselves to
any theory on nervous activity or sleep, it will be seen
that our experiments confirm those of Cavazzani.
Intea-vasculae Injection of the Cbrebro-spinal Fluid.
For some time Professor Halliburton, in conjunction
with Dr. Mott, F.E.S., has been engaged in examining
the results of injecting into animals cerebro-spinal fluid
removed from cases of brain atrophy, especially from
cases of general paralysis of the insane. This fluid con-
tains a toxic substance, choline, doubtless derived from
the disintegration of lecithin in the braiu. Injection of
such fluid into the jugular vein of animals (dogs, cats,
rabbits), an^sthetised with ether, causes a marked lower-
ing of arterial blood pressure, which is partly cardiac in
origin, but principally due to the local action of the
poison on the neuro-muscular apparatus of the peripheral
vessels, especially in the splanchnic area.^
Professor Halliburton was good enough to make simi-
1 'Physiol. Soc. Proc.,' Feb., 1897, and Feb., 1898 ('Journ. of Physiol '
vol*, xxi and xxii).
128
THE CKUEBRO-SPINAL FLUID.
lar experiments with the fluid obtained from my patient.
Quantities varying from 7 to 10 c.c. were injected into the
circulation in dogs, but with entirely negative results.
Such a quantity in the case of fluid from a general
paralytic would be quite sufficient to cause a marked fall
of arterial pressure.
Similar negative results, both as regards blood pressure
and respiration, were obtained with other specimens of
normal cerebro-spinal fluid removed from other animals,
or from cases of meniugocele and hydrocephalus in chil-
di'en. In all such cases, also, choline was searched for
chemically, but with negative results.
The Inpluencb of Straining and Posture on the Flow
AND Composition of the Fluid.
In a monograph on the cerebral circulation ^ Leonard
Hill has put forward the view that the rate of secretion
of the cerebro-spinal fluid, when the cranio-vertebral
cavity is opened, depends directly on the difference
between the pressure in the cerebral capillaries and that
of the atmosphere. He has also shown that cerebral
capillary pressure varies directly and absolutely with vena
cava pressure. Thus the cerebral capillary pressure can
be raised with great ease by any agency which causes a
rise of pressure in the vena cava or cerebral veins. On
the other hand, cerebral capillary pressure varies directly,
but only proportionately, with aortic pressure, for between
the aorta and the capillaries there lies the peripheral
resistance.
It follows from the above that the easiest methods of
raising the cerebral capillary pressure iu man are —
(a) By compression of the abdomen.
[b) By the assumption of the horizontal posture. In
this position, however, the rise of venous pres-
1 ' The Physiology and Pathology of the Cerebral Circulation,' by Leonard
Hill. London : Messrs. Churchill, 1896.
EFFECTS OF STRAINING AND POSTURE.
129
sure may be compensated by the fall of arterial
pressure, whicli normally occurs when tbe body
is at rest. This is, no doubt, the case during
sleep.
(c) By straining or forced expiratory effort, with the
glottis closed.
By all these methods the vena cava pressure is con-
siderably raised; and by the last method the venous
inlets into the thorax may be completely blocked, and the
pressure in the cerebral capillaries raised to something
like aortic pressure.
It is true that, by such a forced expiratory effort, the
aortic pressure is lowered. Nevertheless, the total effect
on capillary pressure is a very great rise, for a fall of
aortic pressure of 25 mm. of mercury produces a fall in
cerebral capillary pressure of less than 5 mm. of mercury,
Avliile a rise of vena cava pressure of 25 mm. of mercury
produces a rise of cerebral capillary pressure of 25
mm. Hg.
My patient's case presented a unique opportunity for
testing the correctness of these views on the living human
subject. I therefore invited Dr. Leonard Hill to suggest
any observations he might wish made, and I had the
pleasure of assisting him in a series of experiments which
entirely confirm his views.
As will be seen from the following figures, the flow of
cerebro-spinal fluid is accelerated by all those circum-
stances whicli raise the cerebral capillary pressure. The
increase in flow is, moreover, accompanied by a decrease
in the percentage of solid matter.
As in all the other observations, the chemical investiga-
tion of the fluid was performed by Professor Halliburton.
We first of all made the following observations : —
1. Patient sitting quietly without straining. In five
minutes 23 minims (TSS? c.c.) were collected.
2. Patient sitting and straining. In five minutes 35
minims (1*965 c.c.) were collected.
3. Patient sitting quietly. In five successive minutes
I
130
THE CEREBRO-SPINAL FLUID.
the amounts collected were respectively 8, 7, 5, 5, 5
drops. The total measured 19 minims (1-021 c.c).
4. Subsequent to this, five minutes were occupied by
the patient in straining, and the amounts collected in
consecutive minutes were 12, 10, 8, 9, and 10 drops
respectively. The total measured 33 minims ( 1*947 c.c).
5. Patient lying down and not straining. The drops
fell as follows in five consecutive minutes 9, 6, 5, 5, and
5, and the total measured 27 minims (1*593 c.c). Here
the arterial pressure was probably not decreased owing
to mental excitement, while the cerebral venous pressure
was increased.
6. Patient lying flat on the stomach and head hanging
over the end of a sofa. The drops fell as follows in five
consecutive minutes — 8, 7, 6, 7, and 7. The total
measured 28 minims (1*652 c.c).
7. Finally, after the last experiment, the following
was collected during quiet dropping, while the patient
was sitting with the head forward. The drops fell as
follows : 5, 4, 4, 4, and 4, in five successive minutes ;
and the total measured 15 minims (0*885 c.c).
The following is the report on the chemical examina-
tion of the fluids : —
So far as the small quantities available admit of
analysis, the fluids are the same qualitatively. The
liquid which escaped passively, and that which passed
under straining, both contained a small quantity of
organic and inorganic solids. Among the organic sub-
stances present are the reducing substance and a trace of
proteid. Judged by the amount of precipitate produced
by alcohol in equal amounts of the two fluids, the proteid
is less abundant in the fluid passed during straining, but
the amount is too small to weigh.
Determination of the total solids gave the following
results, expressed in percentages : —
A. The fluid passed passively, 1*1 per cent.
B. The fluid passed during straining, 0*43 per cent.
Even the higher of these numbers is less than in cases
RESULT OF ABDOMINAL COMPRESSION.
131
of cerebro-spiual fluid from meningocele and hydro-
cephalus (W. D. Halliburton).^
In addition to the foregoing, two specimens were
collected at home by the patient herself. Analysis of
these gave the following results : —
A. Fluid collected while patient was sitting upright
quietly. The percentage of solids was 1*11.
B. Fluid collected while she was lying down. The
percentage of solids was 1*03.
The effect of the horizontal posture is in the same
direction, though not so marked as the effect of straining.
This is what was to be expected, for the horizontal
posture would not raise the venous, and thus the cerebral
capillary pressure so much as powerful expiratory efforts
would. Moreover, the arterial pressure falls during quiet
rest in the recumbent posture, as Dr. Leonard Hill has
determined.^
In order to note the eflfects of straining on the retinal circulation,
Mr. Vernon Cargill was asked to examine the patient, and he kindly
reported as follows : — " I noticed that when a straining effort was
made, a decided but transitory narrowing of the retinal arteries on
and adjacent to the disc occurred, and also a marked pulsation in
the trunks of the retinal veins."
The transitory narrowing of the arteries points to the temporary
lowering of the aortic pressure, while the pulsation of the veins is
a sign of the capillary engorgement due to venous congestion.
Experiments made with Abdominal Compression.
These experiments were made in order to complete
and confirm those just recorded. The patient was seated,
and I compressed the abdomen as firmly and evenly as
possible by spreading both hands over the front of it. The
number of drops per minute were counted as before, and
periods of compression lasting five minutes were alter-
^ ' Journ. of Physiol.,' vol. x, p, 232.
2 ' Ph) s. See. Pi oc.,' January 15fcL, 1898.
132
THE CEREBRO-SPINAL FLUID.
nated with periods of tlie same duration, during which
the patient was sitting quietly.
The following table gives the results succinctly : —
Condition of patient.
Drops in successive minutes
Totiil collected.
A. Abdomen comjircssed ...
C. Abdomen compressed ...
11, 9, 8, 7, 5
4, 5, 3, 4, 4
11, 8, 8, G, G
6, 7, 8, 6, 6
Minims. c.c.
27 1-593
14 0-826
24 1 1-416
Measurement omitted.
The fluids from experiments " A " and " C " were
mixed together; also those fi*om expei-iments B " and
" D." Determination of the total solids gave the follow-
ing results : —
A " and " C." Fluid collected during abdominal
compression. Percentage of solids, 0'68.
''B" and '^'D." Fluid collected while the patient
was sitting upright quietly. Percentage of solids,
1-14.
The experiments confirm those recorded in the pre-
ceding section. Abdominal compression raises the vena
cava pi'essure, and so leads to increased cerebral capillary
pressure, and in this way to increase in the volume of
the cerebro-spinal fluid secreted. Increase of volume, as
before, is accompanied with fall in the percentage of
solids present.
INDEX.
PAGE
Abdominal compression : influence on flow of cerebi'o-spinal fluid . 131
Alexander, on so-called dropsy of antrum . . .93
Althaus, Dr. J., on nasal hyper-secretioa due to vaso-motor neuritis . 95
Analysis of fluid . 27, 29, 33, 38, 40, 51, 52, 58, 60, 61, 63, 68, 71
of cerebro-spinal fluid, by Dr. Hewlett . • .17
by Prof. Halliburton . . . .17
of morning and evening cerebro-spiual fluid . . . 127
of persistent dropping fluid from orbit . . .97
of secretion in nasal hydrorrhcea ... 83, 84
Anderson (A. R.), nasul hydrorrhcea . . . .88
Antrum : case of polypi of antrum, with most probable cerebro-spinal
rhinorrhcea . . • • .51, 100, 101
diagnosis of cerebro-spinal fluid from so-called dropsy of antrum . 88
mucocele of . . • • • .92
so-called dropsy of antrum . . . 91 — 93
denied . . . • • .91
See also Sinus (maxillary).
Atrophy of optic nerves with undoubted cerebro-spinal rhinorrhcea 31, 40
associated with most probable cerebro-spinal rhinorrhcea 59, 60, 02
post-neuritic, of optic nerves in case of hydrocephalus with un-
doubted cerebro-spinal rhinorrhcea . . . .26
Baber (E. Cresswell), cases of mucocele of frontal sinus . . 93
Baxter (E. B.), case of paroxysmal clonic spasm of left rectus abdominis,
with symptoms pointing to existence of gross intra-crauial disease
(associated with rhinorrhcea, most probably cerebro-spinal) 56, 102
Berg (A.), hydrops of the sphenoidal sinus; trephining the sphenoid
cavity ; cure (case of possible cerebro-spinal rhinorrhcea) . 70
(John), case of most probable cerebro-spinal rhinorrhcea . 63
Berger, his denial of condition of dropsy of antrum . . 91
Bidloo (the elder), on escape of cerebro-spinal fluid from nose after
injury . • • • • .8
Blandin, on escape of cerebro-spinal fluid from nose nfter injury . 8
E
134
INDEX.
PAGE
Bond (J. W.), ciises of mucocele of frontal siuus . . .93
Brain: early observers on watery humour in brain . . • ^
supposed passage from brain through nasal cavity . • ^
symptoms of gross intra-cranial disease in case of paroxysmal
clonic spa^-m of left rectus abdominis (associated with rliinorrlicea,
most probably cercbro-spinal) . . . 56, 102
Cameron (Hector), on escape of cerebro-spinal fluid from nose after
injury , , . . . . . 8, 9
Cavazzani, experiments to compare composition of morning and evening
cerebro-spinal fluid . . . • • 125
Cerebi-al symptoms in cases of cerebro-spinal rhinorrlioea . . 114
Cessation of flow of cercbro-spinal fluid . . . 107, 108
Chatin, on escape of cerebro-spinal fluid from ear after injury . 5
Cliemical composition of cerebro-spinal fluid . . .86
See also Analysis.
tests for cerebro-spinal fluid .... 104
Compression, abdominal : influence on flow of cerebro-spinal fluid . 131
Corpora quadi igemina : tumour of corpora quadrigemina, with hydro-
cephalus and possible cerebi'o-splnal rhlnorrhoea . . 68
Cotugno, on cerebro-spinal fluid . . . .4
Cows : mucoceles common in cows . . . .90
Cranium : route of exit of cerehro-spinal fluid from cranial cavity 116 — 120
Crystals of pyrocatechiu, probably those contained in cerebro-spinal
fluid . . . . . .18,105
Dease, cases of escape of cerebro-spinal fluid from ear after injury . 5
Deschamps, on escape of cerebro-spinal fluid from ear after injury . 5
Diagnosis of cerebro-spinal fluid from so-called dropsy of antrum . 88
— — of cerebro-spinal fluid from hyper-secretion in vaso-motor neu-
ritis ...... 95
fro II water inspired and I'etained . . .94
of cerebro-spinal rhinorrlioea from nasal hydrorrhcea . 81, 85
— from ruptured lymph-tubes . . .95
Dropsy of antrum, so-called .... 91 — 93
denied . . . . . .91
diagnosis from cerebro-spinal fluid . . .88
See also Hydrops.
Ear : cerebro-spinal fluid escaping from ear after injury . . 5
spontaneous escape of cerebro-spinal fluid from ear . . 6
EUiotson (John), liquid watery fluid in very large quantities from the
left nostril (case of most probable cerebro-spinal rhinorrhcca) . 50
Emrys- Jones, atrophy of the optic nerves associated with dropping of
fluid from the nostrils . . . . .62
Escat, on spontaneous escape of cerebro-spinal fluid from ear . . 6
Evening and morning cerebro-spinal fluid, result of comparison . 125
INDEX.
135
PAGE
Eye : analysis of persistent dropping fluid from orbit . . 97
lyinph-najvus and other lymphatic derangements of eye and
appendages . . . • • .96
ocular lesions associated with cerebi-o-spinal rhinorrhcea . 108
See also Nerves (optic); Neuriti.t (optic).
Fischer (H.), case of most probable cerebro-spinal rhinorrhcea . 54
Flatau, case of possible cerebro-spinal rhinorrhcea . . .71
on route of exit of cerebro-spinal fluid from cranial cavity . 118
Flow of cerebro-spinal fluid from nose intermittent . . 21
Fossse, nasal, sterility . • • • .20
Foster (Prof. M.), on quantity present of cerebro-spinal fluid . 105, 106
Galen, on cerebro-spinal fluid . . . • .3
Giraldes, on mucous glands of maxillary sinus . . .90
Gland, pituitary. See Fituitary gland.
Glands, mucous, of maxillary sinus . . • 89 91
Goubaux, on mucoceles in cows . . • .90
Groh, case of possible cerebro-spinal rhiuorrhcea . . .69
Guthrie, on escape of cerebro-spinal fluid from ear after injury . 5
Gutsche, case of struma pituitaria (swelling of pituitary gland with un-
doubted cerebro-spinal rhinorrhcea) . . . .33
Halliburton (Prof. W. D., F.E..S.), chemical analysis of secretion in
nasal hydrorrhcea . . • • 83, 84
complete analysis of cerebro-spinal fluid . . .17
experiments on iutra-vascular injection of cerebro-spinal fluid . 127
on cerebro-spinal fluid . . • • .3
in general paralysis of insane . • • 105
states that cei ebro-spinal fluid is not a serous exudation . 98
Haramarsten, on chemical composition of cerebro-spinal fluid . 87
Headache, recurrent : each attack relieved by discharge through right
nostril of fluid from cranial cavity . . • .38
Hewlett (Dr. R. T.), analysis of cerebro-spinal fluid . . 17
Hill (Dr. Leonard), on influence of straining and posture on flow and
composition of cerebro-spinal fluid . . • • 128
result of removal of cerebro-spinal fluid . . • 106
Hoppe-Seyler, on chemical composition of cerebro-spinal fluid . 86
Hydrocephalus internus . . • • 109—111
with tumour of corpora quadrigemiua and possible cerebro-spinal
rhinorrhcea . . • • • .68
with undoubted cerebro-spinal rhinorrhcea . . .26
Hydrops of sphenoidal sinus ; trephining of sphenoid cavity ; cure . 70
See also Dropsy.
Hvdrorrhcea, nasal : analysis of secretion . • 83, 84
, 81, 88
cases . . • • • '
diagnosis from cerebro-spinal rhinorrhcea . 81, 85
136
INDEX.
Injection, intra-vasoular, of ccrehro-spinal fluid .
Injury : escape of corebro-spinal fluid from oar after injiiry •
from nose after injury
Intermissions in flow of cerebro-spiual fluid
Intra- vascular injection of ccrebro-spinal fluid
James (Prosser), case of possible cerebio-spinal rliinorrlioDa .
Key, on route of exit of cerebro-spiual fluid from cranial cavity
King, case of most probable cerebro-spiual rbinnrrlicea
Korner, flow of cerebro-spinal fluid tbrougb nose with optic atrophy
probably caused by tumour of pituitary body breaking into sphe
noidal sinus (undoubted cerebro-spinal rhinorrhoea)
Laugier, on escape of cerebro-spinal fluid from ear after injury
Leber (Tli.), case of liydrocephalus with post-neuritic atrophy of optic
nerves (undoubted cerebro-spinal rhinorrhoea)
Lenoble (E.) and Toison (J.), case of undoubted cerebro-spinal rhinor
rhcea ......
Lichtwitz, case of most probable cerebro-spinal rhinorrhoea . 64,
Lymph : difference between lymph and cerebro-spitial fluid .
Lymph-naevus .....
Lymph-tubes : diagnosis of cerebro-spinal fluid from ruptured lymph
tubes ......
Mackenzie (F. Wallace), case of atrophy of optic nerves with un
doubted cerebro-spinal rhinorrhoea .
MacMunn, qualitative examination of Mules' case of persistent droppinf
of fluid from orbit ....
Magendie, his opinion that cerebro-spinal fluid is reproduced with great
rapidity ....
' Recherches sur le liquide cephalo-rachidien ' (1842)
Magitot, his denial of condition of dropsy of antrum
Massa, on watery humour in brain
Mathiesen, case of traumatic cerebro-spinal rhinorrhoea
Maxillary sinus. See Sinus.
Meningo- encephalitis consequent on exploration of supposed frontal
sinus with undoubted cerebro-spinal rhinorrhoea
Mermod, meningo-encephalitis consequent on exploration of supposed
frontal sinus with undoubted ccrebro-spinal rhinorrhoea
Meyer (Edward), case of possible cerebro-spinal rhinorrhoea
Morgagni, case of possible cerebro-spinal rhinorrhoea
Morning and evening cerebro-spinal fluid : result of comparison
Mott (F. W., F.R.S.), experiments on intra-vascular injection of cerebro
spinal fluid .....
on cerebro-spinal fluid in general paralysis of insane .
Mucocele of antrum of Highmore
PAGE
127
5
7,9
21
127
71
117
49
40
26
28
, 102
98
96
95
81
97
105
3
91
3
9
34
34
69
68
125
127
105
92
INDEX.
137
PAGE
Mucoceles , . , . . , 90, 91
common in cows . . . . .90
Mucous glands. See Olands (mucous).
Mules: lymph nsevus and other lymphatic derangements of the eye and
its appendages (dropping from nose due to rupture of over-distended
lymph-tubes) . . . . . .96
Nsevus. See Lymph-wtuwxs.
Nawratzki, on chemical composition of cerehro-spinal fluid . . 87
Nelaton, on escape of cerehro-spinal fluid from ear after injury . 5
Nerves (optic) : atrophy of optic nerves associated with most probable
cerehro-spinal rhinorrhcca .... 59, 60, 62
atrophy of optic nerves with undoubted cerehro-spinal
rhinorrhoea ..... 31, 40
post-neuritic atrophy of optic nerves in case of hydro-
cephalus with undoubted cerehro-spinal rhinorrhoea . . 26
Nettleship (Edward), case of optic neuritis, followed by dropping of
fluid from the nostril (most probable cerehro-spinal rhinorrhoea) . 57
Neuritis, optic, followed by most probable cerehro-spinal rhinon'hcca . 57
vaso-motor, diagnosis of secretion in vaso-raotor neuritis from
cerebro-si)inal rhinorrhoea . . . . .95
Noltenius, cases of so-called dropsy of antrum . . .92
Nose, cases in which discharge was undoubtedly cerehro-spinal fluid . 13,
24—49
possibly cerehro-spinal fluid . . . 67 — 72
probably cerehro-spinal fluid . . . .49
escape of cerehro-spinal fluid from nose after injury . . 7
supposed passage from brain through nasal cavity . . 4
sterility of nasal fossae . . . . .20
spontaneous escape of cerebro-spinal fluid from nose not a re-
cognised symptom . . . . .10
See also RhinorrhcBa (cerebro-spinal).
Nostril (left) : preponderance of cases in which fluid escaped from left
nostril. ...... 106
Nothnagel, on route of exit of cerebro-spinal fluid from cranial cavity . 118
tumour of the corpora quadrigemina ; hydrocephalus; escape of
cerebro-spinal fluid through nose . . . .68
Ocular lesions associated with cerebro-spinal rhinorrhoea , . 108
O'Halloran, cases of escape of cerebro-spinal fluid from ear after injury 5
Optic nerves. See Nerves (optic).
neuritis. See Neuritis (optic).
Paget (Sir James, Bart.), case of polypi of antrum in which watery fluid
dropped from nostril (most probable cerebro-spinal rhinorrhoea) . 51,
100, 101
Paralysis : cerebro-spinal fluid in general paralysis of insane . . 105
138
INDEX.
PAGE
33
40
Pituitary gland : swelling of pituitary gland (struma pituitaiia) with
undoubted cei'ebro-spinal riiinorrhoea
tumour of pituitary body breaking into sphenoidal sinus,
probably causing flow of cerebro-spinul fluid through nose with
optic atrophy ......
Polypi of antrum with most probable cerebro-spinal riiinorrhoea 51, 100, 101
Posture : influence of straining and posture on flow and composition of
cerebro-spinal fluid ..... 128
Poulsson (E.), case of hydrorrhcea nasalis . . .81
Pyrocatechin : crystals of pyrocatechin, probably those contnined in
cerebro-spinal fluid .... 18, 105
Quincke, on hydrocephalus internus
110, 111
Rabourdin, on escape of cerebro-spinal fluid from ear after injury . 5
Rectus abdominis : paroxysmal clonic spasm of left rectus abdominis
with symptoms of gross iutra-cranial disease (associated with
rhinorrhoea, most probably cerebro-spinal) . . 56, 102
Retzius, on route of exit of cerebro-spinal fluid from cranial cavity . 117
Rhinorrhoea, cerebro-spinal, traumatic . . . .9
~ spontaneous, analysis of secretion 17, 27, 29, 33, 38, 40,51, 52,
58, 60, 61, 63, 68, 71
13-
chemical composition of secretion
cerebral symptoms
diagnosis from so-called dropsy of antrum
from hyper-secretion in vaso-niotor neuritis
from nasal hydrorrhcea .
from ruptured lymph-tubes
of secretion from water inspired and retained
pathology ....
treatment ....
spontaneous cessation of attacks
generally unilateral .
undoubted cases
table of cases .
summary
in case of hydrocephalus, with post-neuritic
optic nerves ....
in case of atrophy of optic nerves .
in case of struma pituitaria
in case of meningo-encephalitis
relieving attacks of recurrent headache
with optic atrophy, probably caused by tumour
pituitary body breaking into sphenoidal sinus .
most probably cerebro-spinal
table of cases
summary ....
86
114
88
95
81, 85
95
94
109
120
107, 108
. 107
23, 24—49
46, 47
. 48
trophy of
. 26
. 31
. 33
. 34
. 38
of
. 40
49—67
74—79
. 80
INDEX.
139
Rhiuorrlioea, most probably ccrebro-spinal, in a case oE polypi of antrum 51
iu a case of paroxysmal clonic spasm of left rectus abdominis
with symptoms pointing to existence of gross intra-craniaVdisease 56, 102
associated with atrophy of optic nerves and other brain
symptoms ..... 59, 60
following optic neuritis . . . .57
possibly cerebro-spinal .... 67 — 71
in case of tumour of corpora quadrigemina and hydrocephalus 68
• • (hydrops of sphenoidal sinus) . . .70
Robert, on escape of cerebro-spinal fluid from ear after injury . 5
from nose after injury . . . .8
Sansovino, on supposed passage from brain through nasal cavity . 4
Sappey, on mucous glands of maxillary sinus . . .89
Scheppegrell, case of recurrent headache, each attack relieved by dis-
charge through right nostril of fluid from cranial cavity (un-
doubted cerebro-spinal rhinorrhoea) . . . .38
Schneider, ou supposed passage between nose and ventricles of brain . 4
Schwalbe, on route of exit of cerebro-spinal fluid from cranial cavity . 117
Serous accumulation in maxillary sinus . . . .89
exudation : cerebro-spinal fluid not a serous exudation . 98
Silcock (A. Q.), on cause of distension of frontal sinus . . 93
Sinus, frontal, cause of distension . . . .93
mucocele of ... . 92, 93
maxillary : mucous glands . . . 89 — 91
serous accumulation in . . . .89
sphenoidal: hydrops of sphenoidal sinus; trephining sphenoid
cavity ; cure . . . . . .70
tumour of pituitary body breaking into sphenoidal sinus,
probably causing flow of cerebro-spinal fluid through nose, with
optic atrophy . . . . . .40
Smith (Priestley), persistent dropping of fluid from the nostril, asso-
ciated with atrophy of the optic nerves and other brain symptoms 59, 60
Spasm, paroxysmal clonic, of left rectus abdominis with symj)toms of
gross intra-ci'anial disease (associated with rhinorrhoea, most pro-
bably cerebro-spinal) .... 56, 102
Speirs (W. R.), notes of a case in which the principal symptom was a
constant and copious discharge of watery fluid from the nose (case
of most probable cerebro-spinal rhinorrhoea) . . 55, 102
Sphenoidal sinus. See Sinus (sphenoidal).
Spontaneous escape of cerebro-spinal fluid from ear . . 6
escape of cerebro-spinal fluid from nose not a recognised sym-
ptom . . . • . • .10
Sterility of cerebro-spinal fluid . . . .20
of nasal fossae . . . . . .20
Straining: influence of straining and posture on flow and composition
of cerebro-spinal fluid ..... 128
140
INDEX.
PAGE
Struma pituitaria (swelling of pituitary glaud) with undoubted cerebro-
spinal rhinorrhcca . . . . .33
Swelling of pituitary gland : sec Struma pituitaria.
Thomson (StClair, M.D.), case of spontaneous cerebro-spinal rhinor-
rhcea ...... 13—23
Tillaux, case of undoubted cerebro-spinal rhinorrhcca . . 24
Toison (J.) and Lenoble (E.), case of undoubted cerebro-spinal rhinor-
rhcea . . . . . • .28
Tumour of corpora quadrigemina and hydrocephalus with possible
cerebro-spinal rhinorrhcea . . . . .68
of pituitary body breaking into sphenoidal sinus probably causing
flow of cerebro-spinal fluid through nose with optic atrophy . 40
Varoli, on watery humour in brain . . . .3
Vaso-motor neuritis. See Neuritis (vaso-motor).
Vesalius, on watery humour in brain . . . .3
Vieusse, case of traumatic cerebro-spinal rhinorrlicea . . 9
on route of exit of cerebro-spinal fluid from cranial cavity . 118
Vieussens, on cerebro-spinal fluid . . . .4
Vidus-Vidius, on watery humour in brain . . .3
Water inspired and retained, diagnosis of cerebro-spinal fluid from . 94
Wiel (Stalpartius van der), on escape of cerebro- spinal fluid from ear
after injury . . . . . .5
Willis (Thomas), on cerebro-spinal fluid . . . .4
case of possible cerebro-spinal rhinorrbcDa . . 67
Wright (Jonathan), on mucocele . . . 91, 92
on mucocele of antrum of Highraore . . .92
on mucocele of frontal sinus . . . .92
Zuckerkandl, on mucous glands of maxillary sinus . . 89
on route of exit of cerebro-spinal fluid from cranial cavity . 117
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